Active Surveillance Versus Watchful Waiting for Localized Prostate Cancer: A Model to Inform Decisions

Background An increasing proportion of prostate cancer is being managed conservatively. 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-specific antigen every 3–6 mo, biopsy every 1–5 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 benefits (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 subsequent treatment. Active surveillance extends life more than watchful waiting, particularly for men with higher-risk features, but this is partly offset by decrements in quality of life from delayed treatment. Trade-offs about the intensity of surveillance should be discussed with patients.