title: Active surveillance: patient selection.
abstract: OBJECTIVE
  This is a summary of the current approach to patient selection for active surveillance, including eligibility criteria, current controversies and the role of imaging.
  
  
  RESULTS
  Active surveillance is based on the concept that Gleason 6 prostate cancer is, in most cases, an indolent condition that poses little or no threat to the patient's life. Substantial recent data suggest that Gleason pattern 3 does not have the molecular characteristics of malignancy. A subset of patients harbour more aggressive disease that was missed on the initial diagnostic biopsies, and a smaller group will progress over time to higher grade disease. Active surveillance involves initial expectant management for patients with favourable risk disease, and serial biopsy and prostate-specific antigen (PSA). Most patients with Gleason 6 prostate cancer are candidates. Very low risk patients fulfil the Epstein criteria, with only one or two positive cores, no core with more than 50% involvement and a PSA density of less than 0.15. Low-risk patients have Gleason 6 disease and PSA 10 or less but do not satisfy the Epstein criteria. Higher volume of Gleason 6 disease on biopsy predicts for a higher likelihood of higher grade cancer, but in and of itself should not mandate treatment. Patients with Gleason 7 in whom the extent of Gleason 4 pattern is less than 10% may also be candidates. Patient age, comorbidity and personal preferences must also be considered.
  
  
  CONCLUSIONS
  Active surveillance is an effective and well tolerated method to reduce the overtreatment associated with screen-detected prostate cancer. About 50% of newly diagnosed patients are eligible for this approach. Multiple factors, including patient age, comorbidity, cancer risk category and patient preferences, must be considered.
authors.affiliation: Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Laurence.klotz@sunnybrook.ca
authors.forename: Laurence
authors.initials: L
authors.lastname: Klotz
mesh_terms: D001706:Biopsy; D003952:Diagnostic Imaging / Q000379:methods; D018450:Disease Progression; D004608:Eligibility Determination; D006801:Humans; D007610:Kallikreins / Q000097:blood; D008297:Male; D060787:Neoplasm Grading; D057240:Patient Preference; D018579:Patient Selection; D011237:Predictive Value of Tests; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology / Q000628:therapy*; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D057832:Watchful Waiting
chemical_list: C549870:KLK3 protein, human; D007610:Kallikreins; D017430:Prostate-Specific Antigen