Not to put too many blogs up this week, but a very well balanced article was just published and includes input from my friend Lori Klotz, whose articles have been at the forefront of doing active surveillance. He tried to get an international trial going that would provide some definitive evidence that this is a reasonable alternative. In the trial, men with low-volume Gleason 6 disease were asked if they would sign up to be randomized between immediate therapy versus going on an active surveillance program. We had the protocol open for about two years and could only find 1 or 2 men willing to participate. When you read THIS ARTICLE, you will see that the study was really important, since a significant portion of men go on to get treatment anyway, and that some studies suggest lower survival with this approach. On the other hand, those being watched do not suffer the side effects of definitive therapy. As with screening, there will be no “final answer”. However I really like this statement as an informational piece that I can give patients who are considering this approach. We also still offer targeted focal therapy at our institution as a possible “in between” treatment option – an interesting approach that is still very early in terms of knowing the long term consequences of this treatment. Mike Landess took this approach and has made a nice video blog of his experience. One of the major unanswered questions in all of this is what the optimal formula for followup should be. For example, PSA’s every 3 months, or should it be more often? Should you initiate treatment based on some absolute number, or a change in the doubling time? Should you biopsy every 2 years, or should it be 18 months? What about doing mapping biopsy on everyone who wants to consider active surveillance? So many questions and so little time !