Active surveillance with selective delayed intervention: a biologically nuanced approach to favorable-risk prostate cancer.

Prostate cancer is an indolent, slow-growing disease in many patients and may not pose a threat during a patient's lifetime. The challenge is to identify those patients who are not likely to experience significant progression while offering radical therapy to those who are at risk. To date, molecular markers have failed to provide sufficiently reliable predictive information to influence decision-making. The approach to favorable-risk prostate cancer described in this article uses estimation of prostate-specific antigen doubling time (PSA DT) to stratify patients according to the risk of progression. Patients who select this approach initially undergo management with active surveillance; those who have a PSA DT <or=3 years (based on a minimum of 3 determinations over a period of 6 months) are offered radical intervention. The remainder are closely monitored. In a series of 231 patients in a study by our group, the median doubling time was 7.0 years; 42% had a PSA DT > 10 years and 20% had a PSA DT > 100 years. The majority of patients in this study continue to undergo surveillance. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy for all (which results in overtreatment of patients with indolent disease) and watchful waiting with palliative therapy only (which results in undertreatment of patients with aggressive disease).