Page 30 - An Evidence Review of Active Surveillance in Men With Localized Prostate Cancer

Decisionmaking Tools and Aids Specifically for AS

No study addressed this factor.

Key Question 4. What are the comparative short- and long-term outcomes
of active surveillance versus immediate treatment with curative intent for
localized prostate cancer?
In order to understand the effectiveness of AS relative to active treatment options, studies of
AS need a control group for comparison. As such, we did not include single-arm AS cohort
studies, which cannot address comparative effectiveness questions. However, no study reported
clinical outcomes specifically for AS management strategies with deferred treatment with
curative intent versus immediate definitive treatment. Therefore, there is insufficient evidence to
evaluate the comparative effectiveness of AS management with curative intent versus immediate
definitive treatment in men with localized prostate cancer.
Faced with a lack of studies comparing AS to immediate active treatment, we elected to
evaluate studies that compared other observational management strategies (largely resembling
WW) with immediate treatment. In addition to previously published systematic reviews and
evidence reports, our searches identified two updates from multicenter RCTs (four publications,
three on clinical/quality of life outcomes and one on costs) and 16 cohort studies (3 prospective
and 13 retrospective). Notably, the majority of evidence for this Key Question came from
retrospective analyses of observational studies. Confounding by indication is likely in these
studies, due to the differences in patient characteristics and risk profile between patients treated
with observational strategies and those who received active treatment.

Observational Management Strategies Versus Radical
Prostatectomy

Studies generally reported that men treated with RP had lower all-cause or prostate cancer-
specific mortality rates than men on WW. The development of metastatic disease was assessed
by a single study that found a significant benefit for RP compared to WW. Morbidity of primary
treatment was reported by two studies that suggested an increased risk for urethral stricture (and
procedures to treat it) were less likely among patients on observational management. Quality of
life (QoL) was reported in three studies; the results varied across different domains of QoL
measure.

Observational Management Strategies Versus Radiation Therapy

Studies generally reported that men treated with RT had lower all-cause mortality rates than
men on WW. One study reported prostate cancer-specific mortality information and did not find
a statistically significant difference between RT and observational management. No study
reported on treatment comparisons for the development of metastatic disease. One study did not
find a significant difference in morbidity between observational management and BT or EBRT.
QoL measures and satisfaction with treatment were reported in four studies; the results varied
across different domains of QoL measure.

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