What is the best way not to treat prostate cancer?

Introduction: Selective treatment approaches for prostate cancer (PCa) are warranted given the highly varied nature of the disease and the consequences associated with definitive therapy.

Materials and methods: We present a stepwise overview of strategies optimized to not treat PCa, ranging from improved screening practices that seek to maximize the yield at initial diagnosis, as well as refinements to clinical risk prediction and the performance of active surveillance.

Results: Improved adherence to screening guidelines offering simplistic, rational practice recommendations are poised to improve the performance of early detection strategies. In addition, measures to improve the quality of PCa screening would include greater integration of novel markers with higher specificity for clinically significant disease, in an effort to stem the tide of over-diagnosis and consequential overtreatment of low-grade tumors. For men diagnosed with PCa, the use of validated, multi-variable risk stratification stands to offer greater certainty in initial management choices: consideration of active surveillance for those with low-risk status, and definitive therapy for men with intermediate and high-risk features. We review the efficacy and nature of active surveillance protocols, and offer a context for refinements that may be anticipated with future study.

Conclusions: The question of how best to not treat prostate cancer is often more complex than policies of universal treatment, yet is integral to minimize morbidity of over-treatment in patients with low-risk tumors. An array of refined risk stratification instruments, biomarkers, and genomic assays seek to improve the confidence both prior to, and following diagnosis.