Department of Urology, New York University, New York, NY, USA; Department of Population Health, New York University, New York, NY, USA.
Department of Population Health, New York University, New York, NY, USA.
Eur Urol. 2017 Dec;72(6):899-907. doi: 10.1016/j.eururo.2017.07.018. Epub 2017 Aug 23.
An increasing proportion of prostate cancer is being managed conservatively. However, there are no randomized trials or consensus regarding the optimal follow-up strategy.
To compare life expectancy and quality of life between watchful waiting (WW) versus different strategies of active surveillance (AS).
DESIGN, SETTING, AND PARTICIPANTS: A Markov model was created for US men starting at age 50, diagnosed with localized prostate cancer who chose conservative management by WW or AS using different testing protocols (prostate-specific antigen every 3-6 mo, biopsy every 1-5 yr, or magnetic resonance imaging based). Transition probabilities and utilities were obtained from the literature.
Primary outcomes were life years and quality-adjusted life years (QALYs). Secondary outcomes include radical treatment, metastasis, and prostate cancer death.
All AS strategies yielded more life years compared with WW. Lifetime risks of prostate cancer death and metastasis were, respectively, 5.42% and 6.40% with AS versus 8.72% and 10.30% with WW. AS yielded more QALYs than WW except in cohorts age >65 yr at diagnosis, or when treatment-related complications were long term. The preferred follow-up strategy was also sensitive to whether people value short-term over long-term benefits (time preference). Depending on the AS protocol, 30-41% underwent radical treatment within 10 yr. Extending the surveillance biopsy interval from 1 to 5 yr reduced life years slightly, with a 0.26 difference in QALYs.
AS extends life more than WW, particularly for men with higher-risk features, but this is partly offset by the decrement in quality of life since many men eventually receive treatment.
More intensive active surveillance protocols extend life more than watchful waiting, but this is partly offset by decrements in quality of life from subsequent treatment.
越来越多的前列腺癌患者选择保守治疗。然而，目前尚无关于最佳随访策略的随机试验或共识。
比较观察等待（WW）与不同主动监测（AS）策略之间的预期寿命和生活质量。
设计、地点和参与者：为美国 50 岁及以上、选择 WW 或 AS 保守治疗的局限性前列腺癌患者建立了一个马尔可夫模型，采用不同的检测方案（前列腺特异性抗原每 3-6 个月、每 1-5 年活检或基于磁共振成像）。转移概率和效用均从文献中获得。
主要结局是生存年和质量调整生存年（QALYs）。次要结局包括根治性治疗、转移和前列腺癌死亡。
所有 AS 策略与 WW 相比，都能获得更多的生存年数。AS 时前列腺癌死亡和转移的终生风险分别为 5.42%和 6.40%，而 WW 时分别为 8.72%和 10.30%。除了诊断时年龄>65 岁的队列或治疗相关并发症为长期时，AS 获得的 QALYs 多于 WW。首选的随访策略也取决于人们对短期和长期利益的重视程度（时间偏好）。根据 AS 方案，30-41%的患者在 10 年内接受了根治性治疗。将监测活检间隔从 1 年延长至 5 年，略微缩短了生存年数，QALYs 减少了 0.26。
AS 比 WW 延长寿命的效果更好，尤其是对具有较高风险特征的男性，但这在一定程度上被随后治疗导致的生活质量下降所抵消。
更密集的主动监测方案比观察等待延长寿命，但这在一定程度上被随后治疗导致的生活质量下降所抵消。
