Watchful waiting and active surveillance: the current position.

Watchful waiting, which is also sometimes termed ‘deferred treatment’ or ‘symptomguided treatment’, is an active decision not to treat the patient, who instead is followed closely, and if and when the tumour progresses clinically with or without symptoms, treatment is started. Treatment in this situation has mostly been some kind of hormonal therapy, although in some series also radical treatment has been used. The rationale behind this strategy, which predominantly was used before the advent of PSA testing, was the experience that prostate cancer often had a protracted course and occurred mainly in elderly men with high competing mortality. At that time the incidence-to-mortality ratio was 2–3:1. The outcome studies on watchful waiting usually included what would currently be defined as intermediate-risk tumours, predominantly palpable, and those studies can be followed for up to 25 years. In these studies, ‘hard’ endpoints, e.g. overall survival and disease-specific survival (DSS), are being used. Watchful waiting is still considered to be an option for elderly patients with less aggressive tumours or for patients with limited life-expectancy [8]. The current use of watchful waiting varies worldwide and, e.g. in the USA only ≈ 5% of the patients in the CaPSURE database were managed by watchful waiting in 2002 [9], while in Sweden watchful waiting or active surveillance was used in ≈ 20% of all new cases in 2005 [7].