title: Active surveillance versus surgery for low risk prostate cancer: a clinical decision analysis.
abstract: OBJECTIVE
  We assessed the effect of age, health status and patient preferences on outcomes of surgery vs active surveillance for low risk prostate cancer.
  
  
  METHODS
  We used Monte Carlo simulation of Markov models of the life courses of 200,000 men diagnosed with low risk prostate cancer and treated with surveillance or radical prostatectomy to calculate quality adjusted life expectancy, life expectancy, prostate cancer specific mortality and years of treatment side effects, with model parameters derived from the literature. We simulated outcomes for men 50 to 75 years old with poor, average or excellent health status (50%, 100% and 150% of average life expectancy, respectively). Sensitivity of outcomes to uncertainties in model parameters was tested.
  
  
  RESULTS
  For 65-year-old men in average health, surgery resulted in 0.3 additional years of life expectancy, 1.6 additional years of impotence or incontinence and a 4.9% decrease in prostate cancer specific mortality compared to surveillance, for a net difference of 0.05 fewer quality adjusted life years. Increased age and poorer baseline health status favored surveillance. With greater than 95% probability, surveillance resulted in net benefits compared to surgery for age older than 74, 67 and 54 years for men in excellent, average and poor health, respectively. Patient preferences toward life under surveillance, biochemical recurrence of disease, treatment side effects and future discount rate affected optimal management choice.
  
  
  CONCLUSIONS
  Older men and men in poor health are likely to have better quality adjusted life expectancy with active surveillance. However, specific individual preferences impact optimal choices and should be a primary consideration in shared decision making.
authors.affiliation: Johns Hopkins University School of Medicine, Department of Urology, the James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland 21287-2101, USA.
authors.forename: David
authors.initials: D
authors.lastname: Liu
authors.forename: Harold P
authors.initials: HP
authors.lastname: Lehmann
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Frick
authors.forename: H Ballentine
authors.initials: HB
authors.lastname: Carter
mesh_terms: D000367:Age Factors; D000368:Aged; D003661:Decision Support Techniques; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D011159:Population Surveillance; D011471:Prostatic Neoplasms / Q000601:surgery / Q000628:therapy*; D012306:Risk