EURURO Vol. 72 No. 4

542 656

Platinum Priority – Editorial
Referring to the article published on pp. 534–541 of this issue
Active Surveillance: A Ten-year Journey
Peter C. Albertsen
Department of Surgery (Urology), University of Connecticut Health Center, Farmington, CT, USA
Before the advent of widespread testing for prostate-
specific antigen (PSA), few urologists were concerned about
the treatment of low-risk prostate cancer. Patients pre-
senting with bone pain and cachexia required antiandrogen
therapy to treat symptomatic metastatic disease. Men
found to have localized disease on rectal examination were
usually offered radiation or, occasionally, surgery. Men with
low-grade disease following transurethral resection usually
did very well without additional treatment.
In the early 1990s, PSA testing led to a dramatic increase
in the incidence of prostate cancer Initially, urologists
treated most of these cases, but by the end of the decade
there was growing recognition that prostate cancer inci-
dence rates far exceeded mortality rates. The publication
of the Prostate Cancer Prevention Trial in 2003 dramatized
the existence of a large pool of patients with low-grade
disease. Some 78% of the participants in the placebo group
with a positive prostate biopsy were found to have Gleason
3 + 3 disease or less
Findings from the two large randomized screening trials,
the European Randomized Study on Prostate Cancer
Screening (ERSPC) and the US-based Prostate, Lung, Colon
and Ovary (PLCO), showed that PSA testing preferentially
finds low-risk disease . Of the 72 891 men tested in the
core age group of the ERSPC trial, 9.6% were found to
have prostate cancer, of which 60% of cases were considered
to be of low risk. Results from the PLCO trial were
comparable. Of the 38 343 men tested, 9% were found to
have prostate cancer, of which 66% had Gleason 6 disease or
less. By the mid 2000s, low-risk prostate cancer was the
dominant stage at diagnosis.
Monitoring low-risk prostate cancer rather than imme-
diate intervention, however, is not a new concept. In
2004, Johansson et al published results for a 20-yr
observational cohort study documenting the natural history
of untreated, localized prostate cancer. They concluded that
most prostate cancers diagnosed at an early stage have an
indolent course, although some may progress to active
disease beyond 15 yr of follow-up. We conducted a
retrospective population-based analysis of 767 men with
clinically localized prostate cancer in the state of Connecti-
cut, USA . We also found that men with low-grade
prostate cancers had a minimal risk of dying from prostate
cancer during 20 yr of follow-up. These studies set
the stage for the concept of ‘‘active surveillance.’’ Since
many men with low-risk prostate cancer are unlikely to
experience disease progression, some prefer to be watched
rather than undergo immediate surgery and radiation with
the attendant risks of complications.
Centers offering active surveillance have developed
criteria defining low-risk prostate cancer that usually
restrict candidates to those with low-volume ( 25% of
cores) and low-grade (Gleason score 3 + 3) disease
Several hundred men have been followed for more than
a decade. Unfortunately, clinicians offering active surveil-
lance have encountered a new problem: what is an
appropriate protocol and how long should a patient pursue
this strategy? How often do patients remain on a particular
protocol? This problem does not arise following surgery or
radiation. Patients undergoing definitive treatment are
usually followed with serial PSA measurement. A rising PSA
implies disease progression, and subsequent treatments are
offered. Monitoring men on an active surveillance protocol
is slightly more complex. PSA is often monitored several
times per year and men are often encouraged to undergo
repeat biopsies and imaging with pelvic magnetic reso-
nance imaging. Disease progression is not often easy to
identify. Some men are comfortable with this approach,
available at
journal homepage:
DOI of original article: .
* Department of Surgery (Urology), University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3955, USA.
Tel. +1 860 6793676; Fax: +1 860 6791318.
E-mail address: .
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.