A Narrative Overview of Active Surveillance for Clinically Localised Prostate Cancer

Abstract

Background Active surveillance (AS) is a strategy employed as an alternative to immediate standard active treatments for patients with low or intermediate-risk localised prostate cancer (PCa). Active treatments such as radical prostatectomy and radiotherapy are associated with significant adverse effects which impair quality of life. There is robust data indicating that the majority of patients with lowrisk PCa undergo a slow and predictable course of cancer growth, and hence do not require immediate active curative treatment. AS provides a means to identify patients with low-risk PCa to be monitored closely through regular clinical assessments, PSA testing, imaging using MRI scans and regular repeat prostate biopsies. These measures enable the identification of any change in disease characteristics which indicate progression or increase in cancer extent or aggressiveness, which necessitates active curative treatment. Alternatively, some patients may choose to leave AS to pursue curative interventions due to anxiety or development of adverse effects such as infections from regular repeat biopsies. The main benefit of AS is the avoidance of unnecessary radical treatments for patients at the early stages of the disease, hence avoiding over-treatment, whilst identifying those at risk of progression to be treated actively. The objective of this article is to provide a narrative summary of contemporary practice regarding AS based on a review of the available evidence base and clinical practice guidelines.Elements of discussion include the potential clinical effectiveness and harms of AS, what AS involves from a practical perspective for healthcare professionals, and patient perspectives. The pitfalls and challenges for healthcare professionals undertaking AS due to variable definitions and thresholds are also considered. Data sources We consulted international guidelines, national and international collaborative studies and seminal prospective studies on AS in the management of clinically localised PCa. Therefore this article constitutes a narrative review and critique of the current evidence base regarding AS. Conclusions AS is a feasible alternative to radical treatment options, especially for lowrisk PCa, primarily as a means of avoiding over-treatment for patients with early disease, whilst identifying those who are at risk of disease progression for active treatment. There is emerging data demonstrating the long-term safety of AS as an oncological management strategy. Uncertainties remain regarding variation in definitions, criteria, thresholds and the most effective types of diagnostic interventions pertaining to patient selection, monitoring and reclassification. Efforts have been made to standardise the practice and conduct of AS, and these are continuing. As data from high-quality prospective comparative studies mature, the practice of AS will continue to evolve and outcomes are expected to continue to improve. Implications for nursing practice The practice of AS involves a multi-disciplinary team of healthca...

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