title: Active surveillance and focal therapy for low-intermediate risk prostate cancer.
abstract: Low risk and many cases of low-intermediate risk prostate cancer, are indolent, have little or no metastatic potential, and are not life threatening. Major advances have been made in understanding who these patients are, and in encouraging the use of conservative management in such individuals. Conservative management incorporates the early identification of those 'low risk' patients who harbor higher risk disease, and benefit from definitive therapy. Based on the current algorithm of PSA followed by systematic biopsy, this represents about 30% of newly diagnosed low risk patients. A further small proportion of patients with low risk disease demonstrate biological progression to higher grade disease. Men with lower risk disease can defer treatment, usually for life. Men with higher risk disease that can be localized to a relatively small volume of the prostate may be candidates for focal, prostate sparing therapy. The results of active surveillance, embodying conservative management with selective delayed intervention for the subset who are re-classified as higher risk over time based on repeat biopsy, imaging, or biomarker results, have shown that this approach is safe in the intermediate to long term, with a 1-5% cancer specific mortality at 15 years. Further refinement of the surveillance approach is ongoing, incorporating MRI, targeted biopsies, and molecular biomarkers.
authors.affiliation: Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Canada.
authors.forename: Laurence
authors.initials: L
authors.lastname: Klotz
keywords: Active surveillance; biomarkers; conservative management; focal therapy; low risk prostate cancer; minimally invasive
references.citation: Eur Urol. 2007 May;51(5):1244-50; discussion 1251
references.pmid: 17161520
references.citation: Nat Genet. 2007 Jan;39(1):41-51
references.pmid: 17173048
references.citation: J Urol. 2014 Jan;191(1):60-7
references.pmid: 23770146
references.citation: Cancer Res. 2006 Sep 1;66(17):8347-51
references.pmid: 16951141
references.citation: Eur Urol. 2014 Sep;66(3):395-7
references.pmid: 24411284
references.citation: BJU Int. 2014 Jan;113(1):56-64
references.pmid: 24053685
references.citation: J Urol. 2010 Jul;184(1):131-5
references.pmid: 20478589
references.citation: Dan Med J. 2013 Feb;60(2):A4575
references.pmid: 23461989
references.citation: J Urol. 2011 Mar;185(3):869-75
references.pmid: 21239008
references.citation: Prostate. 2015 Aug 1;75(11):1216-26
references.pmid: 25939480
references.citation: Urology. 2007 Jun;69(6):1117-20
references.pmid: 17572198
references.citation: Cell. 2011 Mar 4;144(5):646-74
references.pmid: 21376230
references.citation: Urology. 2007 Dec;70(6 Suppl):9-15
references.pmid: 18194712
references.citation: J Natl Cancer Inst. 2013 Jul 17;105(14):1050-8
references.pmid: 23847245
references.citation: Cancer J. 2010 Sep-Oct;16(5):544-9
references.pmid: 20890154
references.citation: J Clin Oncol. 2010 Jan 1;28(1):126-31
references.pmid: 19917860
references.citation: Eur J Cancer. 2012 Mar;48(4):538-46
references.pmid: 22300588
references.citation: Lancet Oncol. 2012 Jun;13(6):622-32
references.pmid: 22512844
references.citation: Eur Urol. 2014 Oct;66(4):732-51
references.pmid: 23769825
references.citation: N Engl J Med. 2007 May 10;356(19):1996-7
references.pmid: 17494935
references.citation: J Natl Compr Canc Netw. 2014 May;12(5):686-718
references.pmid: 24812137
references.citation: J Urol. 2015 Jul;194(1):79-84
references.pmid: 25660208
references.citation: Am J Surg Pathol. 2012 Sep;36(9):1346-52
references.pmid: 22531173
references.citation: Eur Urol. 2015 Jul;68(1):123-31
references.pmid: 25465337
references.citation: J Urol. 2004 Apr;171(4):1520-4
references.pmid: 15017211
references.citation: BMC Genomics. 2013 Oct 08;14:690
references.pmid: 24103217
references.citation: Br J Cancer. 2001 Aug 17;85(4):576-83
references.pmid: 11506499
references.citation: Lancet Oncol. 2012 Nov;13(11):e509-17
references.pmid: 23117005
references.citation: Curr Urol Rep. 2015 Jun;16(6):42
references.pmid: 26017850
references.citation: Jpn J Clin Oncol. 2008 Feb;38(2):122-8
references.pmid: 18272471
references.citation: J Endourol. 2015 Oct;29(10):1115-21
references.pmid: 25897467
references.citation: Cancer Res. 2013 Feb 1;73(3):1050-5
references.pmid: 23204237
references.citation: BJU Int. 2012 Apr;109 Suppl 3:40-3
references.pmid: 22458492
references.citation: J Clin Oncol. 2015 Oct 20;33(30):3379-85
references.pmid: 26324359
references.citation: J Urol. 2010 Nov;184(5):1942-6
references.pmid: 20846681
references.citation: BJU Int. 2005 May;95(7):956-60
references.pmid: 15839912
references.citation: BJU Int. 2012 Jun;109(11):1648-54
references.pmid: 22035200
references.citation: Clin Cancer Res. 1997 Dec;3(12 Pt 1):2269-74
references.pmid: 9815624
references.citation: Hum Pathol. 2001 Dec;32(12):1392-7
references.pmid: 11774175
references.citation: Urology. 2007 Dec;70(6 Suppl):27-35
references.pmid: 18194708
references.citation: J Clin Oncol. 2011 Jun 1;29(16):2185-90
references.pmid: 21464416
references.citation: Am J Surg Pathol. 2014 Aug;38(8):1096-101
references.pmid: 24832163
references.citation: Br J Cancer. 2012 Mar 13;106(6):1095-9
references.pmid: 22361632
references.citation: Eur Urol. 2013 Mar;63(3):428-35
references.pmid: 23084329
references.citation: BJU Int. 2015 Aug;116(2):213-9
references.pmid: 25053197
references.citation: J Clin Oncol. 2015 Mar 1;33(7):e38-40
references.pmid: 24638011
references.citation: Eur Urol. 2012 Jul;62(1):55-63
references.pmid: 22445223
references.citation: J Clin Oncol. 2009 Jan 20;27(3):398-403
references.pmid: 19064972
references.citation: J Urol. 2009 Oct;182(4):1371-7
references.pmid: 19683262
references.citation: Cell Cycle. 2007 Dec 15;6(24):3015-20
references.pmid: 18075313
references.citation: BJU Int. 2008 Jan;101(2):165-9
references.pmid: 17850361
references.citation: Eur Urol. 2013 Jan;63(1):125-40
references.pmid: 22743165
references.citation: In Vivo. 1994 May-Jun;8(3):439-43
references.pmid: 7803731
references.citation: Prostate Cancer Prostatic Dis. 2010 Jun;13(2):126-31
references.pmid: 20084081
references.citation: Eur Urol. 2013 Apr;63(4):597-603
references.pmid: 23159452
references.citation: Eur Urol. 2011 Apr;59(4):477-94
references.pmid: 21195536
references.citation: CMAJ. 2014 Nov 4;186(16):1225-34
references.pmid: 25349003
references.citation: J Natl Cancer Inst. 2005 Sep 7;97(17):1248-53
references.pmid: 16145045
references.citation: Cell. 2000 Jan 7;100(1):57-70
references.pmid: 10647931
references.citation: Arch Esp Urol. 2014 Jun;67(5):431-9
references.pmid: 24914842
references.citation: Urol Oncol. 2008 Sep-Oct;26(5):500-5
references.pmid: 18774463
references.citation: Clin Cancer Res. 2003 Oct 15;9(13):4730-4
references.pmid: 14581343
references.citation: J Clin Invest. 2013 Nov;123(11):4918-22
references.pmid: 24135135
references.citation: Ann Intern Med. 2012 Jul 17;157(2):120-34
references.pmid: 22801674
references.citation: Eur Urol. 2013 Dec;64(6):981-7
references.pmid: 23473579
references.citation: Cancer Res. 2006 May 15;66(10):5012-20
references.pmid: 16707422
references.citation: Eur Urol. 2013 Jan;63(1):101-7
references.pmid: 22980443
references.citation: BJU Int. 2014 Dec;114(6b):E99-E104
references.pmid: 24684511
references.citation: J Urol. 2009 Nov;182(5):2274-8
references.pmid: 19758635
references.citation: Proc Natl Acad Sci U S A. 2006 Jul 18;103(29):10991-6
references.pmid: 16829574
references.citation: Eur Urol. 2015 Apr;67(4):778-86
references.pmid: 25466945
references.citation: Prostate. 2013 May;73(7):778-87
references.pmid: 23169245
references.citation: Cancer. 2008 Jun 15;112(12):2664-70
references.pmid: 18433013
references.citation: J Clin Oncol. 2011 Jul 10;29(20):2795-800
references.pmid: 21632511
references.citation: J Urol. 2012 Nov;188(5):1732-8
references.pmid: 23017866
references.citation: Prostate. 2011 Oct 1;71(14):1568-77
references.pmid: 21360566
references.citation: Prostate. 2012 Jun 15;72(9):991-7
references.pmid: 22024950
references.citation: J Clin Oncol. 2013 Aug 20;31(24):2991-7
references.pmid: 23775960
references.citation: Mod Pathol. 2008 Feb;21(2):67-75
references.pmid: 18065961