Leapman Michael S, Carroll Peter R
Department of Urology, Yale University School of Medicine, New Haven, CT.
Department of Urology, University of California San Francisco, San Francisco, CA.
Urol Oncol. 2017 Feb;35(2):42-50. doi: 10.1016/j.urolonc.2016.09.003. Epub 2016 Oct 13.
Selective treatment approaches for prostate cancer (PCa) are warranted given the highly varied nature of the disease and the consequences associated with definitive therapy.
We present a stepwise overview of strategies optimized to not treat PCa, ranging from improved screening practices that seek to maximize the yield at initial diagnosis, as well as refinements to clinical risk prediction and the performance of active surveillance.
Improved adherence to screening guidelines offering simplistic, rational practice recommendations are poised to improve the performance of early detection strategies. In addition, measures to improve the quality of PCa screening would include greater integration of novel markers with higher specificity for clinically significant disease, in an effort to stem the tide of over-diagnosis and consequential overtreatment of low-grade tumors. For men diagnosed with PCa, the use of validated, multi-variable risk stratification stands to offer greater certainty in initial management choices: consideration of active surveillance for those with low-risk status, and definitive therapy for men with intermediate and high-risk features. We review the efficacy and nature of active surveillance protocols, and offer a context for refinements that may be anticipated with future study.
The question of how best to not treat prostate cancer is often more complex than policies of universal treatment, yet is integral to minimize morbidity of over-treatment in patients with low-risk tumors. An array of refined risk stratification instruments, biomarkers, and genomic assays seek to improve the confidence both prior to, and following diagnosis.
鉴于前列腺癌（PCa）疾病性质高度多样以及确定性治疗相关后果，有必要采取选择性治疗方法。
我们逐步概述了优化的不治疗PCa的策略，范围从旨在使初始诊断时的检出率最大化的改进筛查方法，到临床风险预测的完善以及主动监测的实施。
更好地遵循提供简单、合理实践建议的筛查指南，有望提高早期检测策略的效能。此外，提高PCa筛查质量的措施将包括更多地整合对临床显著疾病具有更高特异性的新型标志物，以遏制低级别肿瘤过度诊断及随之而来的过度治疗的趋势。对于被诊断为PCa的男性，使用经过验证的多变量风险分层在初始管理选择中能提供更大的确定性：对低风险状态者考虑主动监测，对具有中高风险特征的男性进行确定性治疗。我们回顾了主动监测方案的疗效和性质，并为未来研究可能预期的改进提供了背景。
如何最好地不治疗前列腺癌的问题通常比普遍治疗政策更为复杂，但对于将低风险肿瘤患者过度治疗的发病率降至最低至关重要。一系列完善的风险分层工具、生物标志物和基因组检测方法旨在提高诊断前后的可信度。
