Klotz Laurence. Active Surveillance for Localized Prostate Cancer. A New Paradigm for Clinical Management

2nd ed. — Springer, 2018. — 249 p. — ISBN: 978-3-319-62709-0.When the first edition of this book was published, in 2012, the concept of active surveillance was very controversial. Screening enjoyed widespread public support, overdiagnosis was not acknowledged as a significant health issue, and most patients with low-grade cancer were treated radically. The last 5 years have seen a dramatic change in the management of low- risk prostate cancer. The concept of active surveillance has become widely accepted around the world. In some constituencies, more than 90% of low-risk patients are managed conservatively. In the aftermath of the US Preventive Services Task Force level D recommendation against screening, the risks of overdiagnosis and overtreatment are now universally accepted. Indeed, just prior to the publication of this book, the USPSTF has modified their recommendation to a level C (neutral), largely reflecting the favorable impact of active surveillance on overtreatment, one of the main prior criticisms of screening for prostate cancer. The concept of active surveillance, which was first applied to prostate cancer, has now been explicitly adopted in a number of other cancer sites, particularly DCIS of the breast.
This change has meant a shift in focus. The controversy is no longer about the concept of surveillance; rather, it is about the application. There are now more than 2750 publications on the topic of active surveillance in prostate cancer, and the number is increasing logarithmically.
This textbook is unique in providing a comprehensive view of this rapidly evolving and important field. The book covers both the science and application of active surveillance. The chapters are wide ranging. The first section of the book includes chapters on the problem of overdiagnosis and overtreatment in oncology, how to screen more effectively while minimizing overdiagnosis, a provocative article on the use of fear in medicine, and a thoughtful article on the ethics and legalities of conservative management. The next section reviews the molecular events which underlie disease progression and patient selection, expanding surveillance to patients at the “margin” of low risk and improving follow-up. The lessons (and misinterpretations) of the pivotal Protect and PIVOT trials are reviewed. In the third section, the role of MRI and the use of molecular, germ line, and urine biomarkers are summarized. The next section focuses on the quality of life, decision-making, and informing patients, including how to advise them regarding lifestyle, exercise, and diet. The final section addresses the role of pharmacologic intervention to reduce progression, the update of surveillance around the world, the economics of surveillance, and outstanding research questions in the field.
The authors are a “who’s who” of international prostate cancer experts. They are the most knowledgeable individuals in the world on the topics they are writing about.
Active surveillance has resulted in a significant improvement in the quality of life for hundreds of thousands of men around the world. We encourage practitioners to continue to adopt and refine the approach. Our goal is to reduce the morbidity of treatment while further reducing the mortality from prostate cancer. Our patients and their families will be appreciative.
I would like to thank my wife, Ursula Lotz, and my children, Alex and Betsy, for their inspiration and support.