EURURO Vol. 72 No. 6

Platinum Priority

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Prostate Cancer

Editorial by Chris Bangma and Monique Roobol on pp. 908

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909 of this issue

Active Surveillance Versus Watchful Waiting for Localized

Prostate Cancer: A Model to Inform Decisions

Stacy Loeb

a , b , * , Qinlian Zhou b , Uwe Siebert c , d , e , f , Ursula Rochau c , Beate Jahn c ,

Nikolai Mu¨hlberger

c , H. Ballentine Carter g , Herbert Lepor a , R. Scott Braithwaite b

Department of Urology, New York University, New York, NY, USA;

Department of Population Health, New York University, New York, NY, USA;

Department

of Public Health, Health Services Research and Health Technology Assessment, UMIT

—

University for Health Sciences, Medical Informatics and Technology,

Hall i.T., Austria;

ONCOTYROL

—

Center for Personalized Cancer Medicine, Innsbruck, Austria;

Center for Health Decision Science and Department of Health

Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA;

Department of Radiology, Massachusetts General Hospital, Harvard

Medical School, Boston, MA, USA;

The Brady Institute of Urology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

E U R O P E A N U R O L O GY 7 2 ( 2 0 17 ) 8 9 9 – 9 0 7

ava ilable at

www.sciencedirect.com

journal homepage:

www.eu ropeanurology.com

Article info

Article history:

Accepted July 17, 2017

Associate Editor:

Giacomo Novara

Statistical Editor:

Andrew Vickers

Keywords:

Prostate cancer

Active surveillance

Watchful waiting

Conservative management

Markov model

Abstract

Background:

An increasing proportion of prostate cancer is being managed conserva-

tively. However, there are no randomized trials or consensus regarding the optimal

follow-up strategy.

Objective:

To compare life expectancy and quality of life between watchful waiting

(WW) versus different strategies of active surveillance (AS).

Design, setting, and participants:

A Markov model was created for US men starting at

age 50, diagnosed with localized prostate cancer who chose conservative management

by WW or AS using different testing protocols (prostate-speci

c antigen every 3

–

6 mo,

biopsy every 1

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5 yr, or magnetic resonance imaging based). Transition probabilities and

utilities were obtained from the literature.

Outcome measurements and statistical analysis:

Primary outcomes were life years and

quality-adjusted life years (QALYs). Secondary outcomes include radical treatment,

metastasis, and prostate cancer death.

Results and limitations:

All AS strategies yielded more life years compared with WW.

Lifetime risks of prostate cancer death and metastasis were, respectively, 5.42% and

6.40% with AS versus 8.72% and 10.30% with WW. AS yielded more QALYs than WW

except in cohorts age

65 yr at diagnosis, or when treatment-related complications

were long term. The preferred follow-up strategy was also sensitive to whether people

value short-term over long-term bene

ts (time preference). Depending on the AS

protocol, 30

–

41% underwent radical treatment within 10 yr. Extending the surveillance

biopsy interval from 1 to 5 yr reduced life years slightly, with a 0.26 difference in QALYs.

Conclusions:

AS extends life more than WW, particularly for men with higher-risk

features, but this is partly offset by the decrement in quality of life since many men

eventually receive treatment.

Patient summary:

More intensive active surveillance protocols extend life more than

watchful waiting, but this is partly offset by decrements in quality of life from subse-

quent treatment.

* Corresponding author. 550 1

Ave VZ30 (6

Floor, 612), New York, NY 10016, USA.

Tel. +1 646 501 2559; Fax: +1 212 263 4549.

E-mail address:

[email protected]

(S. Loeb).

http://dx.doi.org/10.1016/j.eururo.2017.07.018