Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
Curr Opin Urol. 2012 May;22(3):222-30. doi: 10.1097/MOU.0b013e328352598c.
Active surveillance has evolved to become a standard of care for favorable-risk prostate cancer. This article is a summary of the rationale, method, and results of active surveillance beginning in 1995 with the first prospective trial of this approach.
This was a prospective, single arm cohort study. Patients were managed with an initial expectant approach. Definitive intervention was offered to those patients with a prostate specific antigen (PSA) doubling time of less than 3 years, Gleason score progression (to 4 + 3 or greater), or unequivocal clinical progression. Since November 1995, 450 patients have been managed with active surveillance. Median follow-up is 6.8 years (range 1-16 years). Overall survival is 78.6%. Ten-year prostate cancer actuarial survival is 97.2%. Five of 450 patients (1.1%) have died of prostate cancer. Thirty percent of patients have been reclassified as higher risk and offered definitive therapy. The commonest indication for treatment was a PSA doubling time less than 3 years (48%) or Gleason upgrading (26%). Of 117 patients treated radically, the PSA failure rate was 50%. This represents 13% of the total cohort. Most PSA failures occurred early; at 2 years, 44% of the treated patients had PSA failure. The hazard ratio for nonprostate cancer to prostate cancer mortality was 18.6 at 10 years.
We observed a very low rate of prostate cancer mortality in an intermediate time frame. Among the one-third of patients who were reclassified as higher risk and retreated, PSA failure was relatively common. However, other cause mortality accounted for almost all of the deaths. Further studies are warranted to improve the identification of patients who harbor more aggressive disease in spite of favorable clinical parameters at diagnosis.
积极监测已发展成为低危前列腺癌的标准治疗方法。本文总结了自 1995 年首次前瞻性试验以来积极监测的原理、方法和结果。
这是一项前瞻性、单臂队列研究。患者最初采用期待疗法进行管理。对于 PSA 倍增时间<3 年、Gleason 评分进展（至 4+3 或更高）或明确临床进展的患者，给予确定性干预。自 1995 年 11 月以来，450 例患者接受了积极监测。中位随访时间为 6.8 年（范围 1-16 年）。总生存率为 78.6%。10 年前列腺癌生存 actuarial 率为 97.2%。450 例患者中有 5 例（1.1%）死于前列腺癌。30%的患者被重新分类为高危，并接受了确定性治疗。最常见的治疗指征是 PSA 倍增时间<3 年（48%）或 Gleason 升级（26%）。117 例根治性治疗的患者中，PSA 失败率为 50%。这代表了总队列的 13%。大多数 PSA 失败发生较早；在 2 年内，接受治疗的患者中有 44%出现 PSA 失败。10 年内非前列腺癌与前列腺癌死亡率的危害比为 18.6。
我们观察到在中期时间框架内前列腺癌死亡率非常低。在三分之一被重新分类为高危并接受治疗的患者中，PSA 失败较为常见。然而，其他原因的死亡率几乎占所有死亡人数。需要进一步的研究来提高识别尽管在诊断时具有有利的临床参数但仍存在更具侵袭性疾病的患者的能力。
