Long-term Psychological and Quality-of-life Effects of Active Surveillance and Watchful Waiting After Diagnosis of Low-risk Localised Prostate Cancer

Authors Egger SJ, Calopedos RJ, O'Connell DL, et al.

Review Date February 2018

Citation Prostate disease


The majority of men diagnosed with low-risk localised prostate cancer opt for active treatment, such as radical prostatectomy or radiation therapy. These treatments are selected despite many localised prostate cancers not leading to death, and the evidence that active treatment bears an increased risk of urinary leakage, bowel problems and sexual dysfunction. Alternative approaches to prostate cancer management include conservative methods such as active surveillance (AS), where clinical management resembles on-going PSA monitoring and biopsy assessment for advanced disease, or watchful waiting (WW), the most non-interventionist strategy. Study cohorts derived from the prospective longitudinal Prostate Cancer Care and Outcome Study (PCOS; NSW) were examined for the psychological and physical impacts of selecting non-active compared to active treatment options at diagnosis. This analysis is informative for the strategic and effective management of low-risk prostate cancer patients for their long-term psychological and physical health outcomes.


The authors aimed to determine the psychological and physical well-being of low-risk localised prostate cancer patients who at diagnosis received non-active versus active treatments at study 10 year follow-up. The authors sought to comprehensively examine a number of active treatments types and a variety of long-term psychological and related physical measures in this study cohort.


Participant study inclusion criteria were completion of baseline and 10 year follow-up surveys, and the presence of low-risk localised prostate cancer at diagnosis (defined as PSA <10, Gleason score <6 and clinical stage T1-T2a), resulting in 341 eligible participants.

Active treatment participants (n=278; 82%) were grouped by their first treatment at diagnosis: radical prostatectomy (n=221), radiation therapy and/or high-dose-rate brachytherapy (HDR; n=25), or low-dose-rate brachytherapy (LDR; n=32). Non-active treatment participants (n=63; 18%) were subdivided into AS/WW then active treatment (n=27), or AS/WW only (n=36). The 10 year survey included a range of clinically validated psychological scales and health-related quality-of-life measures including scores for ‘cancer progression fear’, ‘perceived control over the course of cancer course’, as well as measures of anxiety and depression. Physical domains assessed through survey were urinary problems (incontinence and bother), bowel problems and sexual function. Adjusted mean differences were presented after adjustment for baseline data and a range of other confounders including socio-economic status, educational level, possession of private health insurance and employment status.


Analyses of nine psychological measures and six health-related quality-of-life domains relevant to prostate cancer patients, indicated that patients receiving AS/WW only at initial treatment fared moderately worse in some psychological domains and better in some physical domains, than active treatment patients.

At the 10 year follow-up, the AS/WW low-risk localised prostate cancer group scored worse for levels of distress and hyperarousal compared to men receiving radiotherapy and/or HDR, and worse for distress and cognitive avoidance compared to men receiving LDR. However, the AS/WW group scored better for measures of urinary incontinence and bowel problems compared to radical prostatectomy and radiotherapy/HDR groups, respectively.

The remaining six psychological and four health-related quality-of-life measures were not significantly changed by active versus non-active treatment strategies.


Long-term review of patients diagnosed with low-risk localised prostate cancer suggest that selecting AS or WW over active treatment options is likely to lead to improved physical outcomes (urinary and bowel), but may pose some increased risk of poor psychological health.


Points to Note

  1. This study provided long-term psychological and physical follow-up of low-risk localised prostate cancer patients, having relevance for separating age-related co-morbidity with diagnosis-related progression.
  2. Study findings were consistent with other similar clinical trials, adding to the evidence that conservative management of low-risk prostate cancer is not likely to have a major negative impact on psychological health outcome.
  3. Study limitations noted by the authors include high study attrition rate typical of long-term studies, an inability to separate AS and WW groups, and the potential for recall bias at initial survey.

Website: https://www.ncbi.nlm.nih.gov/pubmed/28851582

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