Active Surveillance for Prostate Cancer

Abstract

Since 1980, the prognosis of prostate cancer has changed markedly as the United States has moved through 3 eras. The first era reflected the experience of the prior century. Because prostate cancer is usually asymptomatic until it is metastatic and rectal examination has a low sensitivity for early cancer detection, most men had advanced and incurable disease at diagnosis. During the second era in the mid-1980s, with the advent of prostate-specific antigen (PSA) testing, at-risk men underwent prostate biopsy, leading to a doubling of incidence rates and a stage shift, with a substantially higher fraction of men with curable disease at diagnosis.¹ This increase in numbers of patients suitable for curative therapy (surgery or radiation) facilitated a reduction in complications and morbidity. The increasing proportion of men achieving long-term cure was gratifying. Even though randomized studies of screening have reached discordant conclusions about how screening affects cure, prostate cancer mortality declined 39% in the United States from 1990 to 2006.²