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Active Surveillance for the Management of Localized Prostate Cancer

ID: 17-9 Dec 2014
Type of Content: Guidelines & Advice, Clinical
Document Status: Current
Authors:
C. Morash, R. Tey, C. Agbassi, L. Klotz, T. McGowan, J. Srigley, A. Evans , Active Surveillance Guideline Development Group

Guideline Objective

  • To describe the role of active surveillance (AS) as a management strategy for patients with localized prostate cancer.
  • To identify patients with prostate cancer that would most benefit from AS.
  • To develop an evidence-based protocol for AS in localized prostate cancer and to identify the factors affecting the offer of, acceptance of, and adherence to AS.
  • To understand the role of 5-alpha reductase inhibitors (5ARI) (e.g., finasteride and dutasteride) in patients with localized prostate cancer undergoing AS.
  • To identify which physician is responsible for managing the AS protocol and if any other human resources required to offer AS (e.g., genitourinary pathologist, psychosocial specialist, etc.) would need specific training.

Patient Population

Men with clinically localized prostate cancer (stage T1 and T2, Gleason score ≤7).

Intended Guideline Users

Clinicians and specialists providing care to patients with prostate cancer (i.e. urologists and radiation oncologists).

Research Question(s)

  1. How does AS compare with immediate active treatments (e.g., RP, RT, brachytherapy, hormone therapy, cryotherapy, or high-intensity focused ultrasound) as a management strategy for patients with newly-diagnosed localized prostate cancer (T1 and T2; Gleason score £7)?
  2. In patients with localized prostate cancer undergoing AS, which findings of the following tests predict increasing risk of reclassification to a higher-risk disease state? What are their test characteristics (i.e., positive and negative predictive values, sensitivities, specificities, and likelihood ratios)?
  • PSA kinetics (e.g., velocity or doubling time)
  • DRE - Imaging (e.g., magnetic resonance imaging [MRI] or ultrasound [US])
  • Prostate cancer antigen3 (PCA3)
  1. In patients with localized prostate cancer undergoing AS, how does supplementation with 5-alpha reductase inhibitors (5ARIs) (e.g., finasteride or dutasteride) compare with no supplementation?
  2. In patients with localized prostate cancer undergoing AS, how do clinical outcomes differ if treatment is managed by a:
    • Single doctor versus a multidisciplinary team of clinicians?
    • Urologist versus another oncologist (e.g., a radiation oncologist)?
    • University/teaching hospital versus a community or private clinic/hospital?
  3. In patients with localized prostate cancer who are candidates for or who are undergoing AS, how does the offer, receipt, or choice of treatment and patient compliance or adherence differ based on (but not limited to) the following factors:
  • AS protocol: order of and frequency of tests (PSA, DRE, imaging), and other test/clinical factors?
  • Care provider(s): single versus team of doctors; urologist versus other oncologist?
  • Care setting: clinic versus hospital?
  • Patient factors: clinical, psychosocial?
  • Social support: family or community?
  • Socioeconomic or geographic variables?
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