EURURO Vol. 72 No. 6

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they choose AS instead of immediate invasive treatment to
avoid overtreatment. It is the predicted overall better QOL
they are choosing , and this is exactly the most uncertain
factor in the modeling.
The article suggests introduction of a new paradigm for
personalized tailoring of diagnostic tests and treatment;
this has been argued before for screening and later stages of
the disease, for example The tailoring (ie, adapting the
frequency of PSA testing or switching to active treatment)
will then be based on an individually assessed probability-
based criterion instead of a rule-based criterion. As we still
are unaware of the value of imaging or genomics in risk
assessment, current designs for this type of probability-
based protocol can only be reliably assessed using large data
sets with sufficient events, such as the data compiled in the
GAP3 Movember database initiative with traditional pa-
rameters
The actual differences in outcome between AS protocols
and WW appear to be small, as illustrated in the traditional
cohorts mentioned above and the data derived from the
current modeling study. Taking into account the burden of
repeat testing, AS may even look worse than doing nothing
(waiting).
But this is 2017, and we have markers, imaging, and
genomics. In many countries around the world, the
acceptance and reliability of AS are very high and still
increasing (in Scandinavian countries and the Netherlands,
95% of men with low-risk tumors are on AS , which
might partly be a result of offering monitoring technology
and of increasing detection of more low-risk tumors.
Especially for men in their fifth or sixth decade of life,
choice of a WW strategy while on conservative manage-
ment is nonexistent: when informed of the current
diagnostic tests, they all opt for AS. The tradeoff between
more and less intense methods of monitoring only counts
for men aged 65 yr. For those aged >75 yr, making a choice
is irrelevant, and one can stop offering or selecting any form
of monitoring. Thus, AS for low-risk prostate cancers is
better than doing nothing, especially for those younger than
65 yr. But doing nothing has already yielded excellent
results, so it remains a challenge how exactly to balance the
benefit of improved clinical outcome versus the harm of
repeat testing.
Most important, however, remains the ability to avoid
diagnosis of low-risk prostate cancers. The harm of
unnecessarily becoming a cancer patient cannot be reversed
by WW or AS.
Conflicts of interest: The authors have nothing to disclose.
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