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Journal of Clinical Oncology, Vol 23, No 6 (February 20), 2005: pp. 1322 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.99.303
Watchful Waiting, Temporarily Deferred Therapy, or Active Surveillance?Academic Urology Unit, Institute of Cancer Research and Royal Marsden Hospital, Sutton, UK To the Editor: I was interested to read the report of Carter et al of a conservative management strategy for early prostate cancer,1 and I agree with the authors that the term "watchful waiting" does not accurately describe their strategy. Given the overdiagnosis and lead-time bias associated with prostate-specific antigen (PSA) screening,2 the natural history of prostate cancer following diagnosis is now far more favorable than it was in the pre-PSA era, making a conservative management strategy an attractive option for many patients. However, clinicians and patients need to understand the important distinctions between the different conservative strategies now available. The term watchful waiting was widely used during the pre-PSA era to describe a policy of observation with palliative treatment for symptomatic cancer progression. Such a policy remains appropriate for patients who, by virtue of age and comorbidities, have a relatively short life expectancy and do not have a radical treatment option. A second, and quite distinct, approach to favorable-risk early prostate cancer is to determine the need for radical treatment based on biochemical or histologic evidence of disease progression during close monitoring. The aim of this approach is to target curative treatment to the minority of patients who need it, so that the majority are spared the side effects of unnecessary treatment. This strategy was first described by Richard Choo et al as, "watchful observation with selective delayed intervention."3 At the Royal Marsden Hospital, we use the term "active surveillance" to describe this strategy.4 These initial studies have demonstrated the feasibility of this approach, which offers patients a realistic hope of avoiding treatment side effects without detriment to their survival. Active surveillance requires a clear definition of the indications for radical treatment (usually based on PSA doubling time and the results of repeat biopsies), together with a commitment to the policy from both patient and clinician. If these are lacking, the result will be "temporarily deferred therapy," as described by Carter et al, in which men with early prostate cancer who are almost inevitably going to have radical treatment, choose to delay such therapy.1 Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Carter CA, Donahue T, Sun L, et al: Temporarily deferred therapy (watchful waiting) for men younger than 70 years and with low-risk localized prostate cancer in the prostate-specific antigen era. J Clin Oncol 21:4001-4008, 2003
2. Draisma G, Boer R, Otto SJ, et al: Lead times and overdetection due to prostate-specific antigen screening: Estimates from the European Randomized Study of Screening for Prostate Cancer. J Natl Cancer Inst 95:868-878, 2003 3. Choo R, Klotz L, Danjoux C, et al: Feasibility study: Watchful waiting for localized low to intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression. J Urol 167:1664-1669, 2002[CrossRef][Medline] 4. Parker CC: Active surveillance: An individualized approach to early prostate cancer. BJU Int 92:2-3, 2003[Medline]
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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