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.

中文翻译：

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主动监视与警惕等待局部前列腺癌：告知决策的模型

背景

保守治疗越来越多的前列腺癌。然而，关于最佳的随访策略尚无随机试验或共识。

客观的

比较观察等待（WW）与主动监视（AS）的不同策略之间的预期寿命和生活质量。

设计，设置和参与者

为美国男性创建了一个马尔可夫模型，从50岁开始，他们被诊断为局限性前列腺癌，他们使用不同的测试方案（每3–6个月进行前列腺特异性抗原检查，每1-5年进行活检或进行磁化检查，选择通过WW或AS进行保守治疗）基于共振成像）。过渡概率和效用是从文献中获得的。

成果测量和统计分析

主要结果是生命年和质量调整生命年（QALYs）。次要结果包括根治性治疗，转移和前列腺癌死亡。

结果与局限性

与WW相比，所有AS策略的寿命都更长。AS的终生风险为前列腺癌死亡和转移的风险分别为5.42％和6.40％，而WW的终生风险分别为8.72％和10.30％。除了在诊断时年龄大于65岁或长期与治疗相关的并发症的队列中，AS产生的QA​​LY比WW多。首选的后续策略还敏感于人们是否看重短期利益而不是长期利益（时间偏好）。根据AS方案，在10年内有30-41％的患者接受了根治性治疗。将监测活检间隔从1年延长到5年会略微缩短生命年，QALYs的差异为0.26。

结论

AS的寿命比WW更长，特别是对于那些具有较高风险的男性，但由于许多男性最终接受了治疗，生活质量的下降在一定程度上抵消了AS的寿命。

病人总结

更加密集的主动监视协议可以延长生命，而不是等待观察，但这可以被后续治疗带来的生活质量下降部分抵消。