EURURO Vol. 72 No. 6

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probability of metastasis and high decrement in utility from
treatment-related complications ).
Two way sensitivity analyses were also performed for
discount rates to characterize the substantial sensitivity to
time preference C). Setting the probability of
treatment-related complications at 0, WWwas the preferred
choice if the discount rate is >0.0023 (below the lower
plausible bound of 0.03). Even at the highest probability of
metastasis used in our sensitivity analysis of 0.002 (or 21% at
10 yr), discounting >0.005 made WW preferred to AS.
4. Discussion
AS extends life more than WW, particularly for men with
higher-risk disease with a greater risk of metastasis.
However, intensive follow-up protocols with frequent
rebiopsy and use of radical treatment for men with grade
reclassification may reduce QOL. Extending the interval
between biopsies up to 5 yr led fewer men to receive radical
treatment, with a small reduction in incremental LYs and
QALYs. Time preferences and duration of QOL decrements
from treatment side effects also had a significant impact on
the results. These findings show the importance of shared
decision making; these trade-offs should be discussed with
patients to provide decisions regarding the intent and
intensity of conservative management options based on
individualized patient preferences .
These results are particularly timely given recent
evidence that the use of conservative management for
PCa is rapidly increasing. In the USA, there was a significant
spike in the use of conservative management up to >40% in
2010–2013 , with similar trends internationally Na-
tionwide Swedish data showed that 91% of very low–risk
and 74% of low-risk patients chose AS in 2014 .
Despite increasing utilization, there are limited data
determining what to do next for men choosing conservative
management and real-world practice patterns vary widely
. A 2011 National Institutes of Health (NIH) consen-
sus conference concluded that “follow-up under AS is
variable and not currently evidence-based. The types of
monitoring and their optimal frequency need to be defined.
It is important to consider whether follow-up should vary
based on tumor and patient characteristics ” . First, there
is no level 1 evidence that AS is superior to WW. Moreover,
for patients choosing AS, there is no consensus on the type,
frequency, or sequence of follow-up tests to monitor for
disease progression That notwithstanding, the choice
of follow-up testing may have significant implications for
patients and healthcare system. PSA and digital rectal
examination are less invasive and costly, but may not
reliably identify disease progression . In a randomized
trial, men with screen-detected PCa monitored primarily
based on PSA kinetics without regularly scheduled biopsies
had a higher risk of metastasis at 10-yr than those who
Table 2 – Comparisons of remaining life expectancy and quality-adjusted life expectancy between active surveillance using different
protocols for men with low-risk prostate cancer, compared with watchful waiting in the cohorts aged 40 yr, 50 yr (base case), 65 yr, 70
yr, and 75 yr
Strategy Remaining life expectancy (LY) Incremental LY Quality-adjusted life expectancy (QALY) Incremental QALY
Cohort aged 40 yr
Watchful waiting 42.94 – 41.47 –
AS—Hopkins 43.96 +1.03 42.36 +0.89
AS—PRIAS 43.81 +0.88 42.20 +0.73
AS—MRI based 43.96 +1.03 42.36 +0.90
AS—5 yr 43.58 +0.64 41.95 +0.49
Cohort aged 50 yr
Watchful waiting 34.55 – 33.36 –
AS—Hopkins 35.21 +0.66 33.89 +0.53
AS—PRIAS 35.12 +0.57 33.79 +0.44
AS—MRI based 35.20 +0.65 33.89 +0.53
AS—5 yr 34.99 +0.44 33.63 +0.27
Cohort aged 65 yr
Watchful waiting 22.60 – 21.80
AS—Hopkins 22.83 +0.24 21.70 –0.10
AS—PRIAS 22.81 +0.22 21.70 –0.10
AS—MRI based 22.83 +0.24 21.71 –0.10
AS—5 yr 22.78 +0.19 21.67 –0.13
Cohort aged 70 yr
Watchful waiting 18.87 – 18.21 –
AS—Hopkins 19.02 +0.14 17.89 –0.31
AS—PRIAS 19.00 +0.13 17.93 –0.28
AS—MRI based 19.01 +0.14 17.89 –0.32
AS—5 yr 18.99 +0.12 18.00 –0.20
Cohort aged 75 yr
Watchful waiting 15.35 – 14.81 –
AS—Hopkins 15.42 +0.07 14.48 –0.33
AS—PRIAS 15.41 +0.06 14.52 –0.29
AS—MRI based 15.42 +0.07 14.47 –0.34
AS—5 yr 15.41 +0.06 14.63 –0.18
AS = active surveillance; LY = life years; QALY = quality-adjusted life years; MRI = magnetic resonance imaging; PRIAS = Prostate Cancer Research International
Active Surveillance.
E U R O P E A N U R O L O GY 7 2 ( 2 0 17 ) 8 9 9 – 9 0 7 902