Prostate Cancer: Active Surveillance Offers Quality-of-Life Gains
'Watchful Waiting' May Offer More Benefits Than Treating the Disease in Select Cases
By Denise Mann
WebMD Medical Reference
Reviewed by Laura J. Martin, MD


Nov. 30, 2010 -- Active surveillance for men with localized prostate cancer may offer up some important quality-of-life advantages when compared to other initial prostate cancer treatments, such as radiation therapy and surgical removal of the prostate gland (radical prostatectomy), according to a new study.

At the end of the day, however, an individual’s preferences still play an important role in making prostate cancer treatment decisions, the study researchers point out in the Dec. 1 issue of the Journal of the American Medical Association.

"The quality-of-life advantage associated with active surveillance is robust,” conclude researchers led by Julia H. Hayes, MD, of the Dana-Farber Cancer Institute at Harvard Medical School in Boston. “This benefit reflects the deferred and substantially lower incidence of adverse effects of treatment experienced by men under active surveillance.” Side effects of prostate cancer treatments can include impotence and incontinence.
What Is Active Surveillance?

Active surveillance is sometimes called watchful waiting. It involves close monitoring of the prostate tumor via tests, digital rectal exams, and  intermittent biopsies with the intent of averting treatment unless or until the cancer progresses.

In 2009, 192,000 U.S. men were diagnosed with prostate cancer. Of these men, 70% would have been diagnosed with low-risk, localized disease, and more than 90% would have undergone treatment.

As many as 60% of men diagnosed with prostate cancer may not require therapy, the researchers point out.

Active surveillance is underused in the U.S. Less than 10% of men who would be eligible for active surveillance choose it for many reasons, including the anxiety that comes with the perception of doing nothing to treat a potentially growing cancer.
Treatments vs. Active Surveillance

Hayes and colleagues developed a model to look at the quality-of-life benefits and risks associated with active surveillance, internal radiation therapy (brachytherapy), intensity-modulated radiation therapy (IMRT), or radical prostatectomy in a hypothetical group of men aged 65 who were diagnosed with localized, low-risk prostate cancer.

Men aged 65 with low-risk prostate cancer who chose active surveillance (with IMRT if the cancer progressed) scored highest in terms of quality-adjusted life expectancy (QALE). This strategy produces 11.07 quality-adjusted life-years (QALY). QALY is a measurement of both quality and length of life, and one QALY reflects a year of life in a healthy state.

Brachytherapy and IMRT were less effective, and radical prostatectomy was the least effective treatment in terms of this measure.  Active surveillance provided six additional months of QALE compared with brachytherapy, which was the most effective initial treatment, the study showed.

“The findings suggest that for men affected by these smaller, lower-grade tumors, active surveillance is a reasonable approach as an initial treatment option, although individual patient preferences must be carefully considered,” write Ian M. Thompson, MD, of the University of Texas Health Science Center in San Antonio and Laurence Klotz, MD, of the Sunnybrook Health Science Center in Toronto, Canada, in an accompanying editorial.

For some men, the quality-of-life gains will not be as pronounced because they will be overcome with anxiety about the cancer, they write.

Accepting Active Surveillance

“Active surveillance is reasonable in a proportion of patients, but this paper should not be misconstrued to think that most patients should have active surveillance at age 65,” says Reza Ghavamian, MD, director of the prostate cancer program at the Montefiore-Einstein Center for Cancer Care and director of urologic oncology and robotic urology at Montefiore Medical Center in New York. “That’s not true.”

Treatment has to be individualized, he says.

“Some patients may say ‘it affects my quality of life, if I know I have a cancer that I am just  watchfully waiting,' and some people say ‘I don’t care as long as doctor is watching it for me,'” he says.

“There should be a wider acceptance of the concept of active surveillance,” says Jeri Kim, MD, an associate professor in the department of genitourinary medical oncology at the University of Texas M.D. Anderson Cancer Center in Houston. But “a lot of people are afraid of having cancer and not doing anything about it, and this study is one of the first to come out that really tells us that it's is a reasonable option for men with low-risk prostate cancer.”