Inspired by Prostate Cancer Awareness Month (September), I wondered what would be considered the most noteworthy advance in prostate cancer (PCa) management in the past 10 years. The possibilities are many, but certainly scientific and therapeutic advances in metastatic castration-resistant PCa that have extended survival by 4–5 months on average must figure large in my analysis, given that PCa causes an estimated 27,540 deaths annually. The therapeutics include sipuleucel-T (a therapeutic vaccine) and radium-223, a first-in-class drug that targets bone metastases with alpha particles, as well as abiraterone acetate, enzalutamide, and cabazitaxel. Clinicians now have available an array of therapeutic choices with which to manage a clinically challenging group of patients.

Although using therapeutics to prolong life is a major goal of medicine, I cannot ignore advances in the screening and management of low-risk PCa that address the formidable challenge of decreasing PCa overtreatment. Multiple randomized trials have shown that the vast majority of prostate tumors have an indolent course, seldom metastasizing and causing death. It became clear that many men with low-risk PCa could safely avoid radical treatment without shortening their lifespan. The result was the emergence of active surveillance as a reasonable first-line management strategy for selected patients. 

Today, many institutions have protocols for monitoring patients for disease progression, offering active treatment when appropriate. Guidelines from the National Comprehensive Cancer Network recommend active surveillance as the sole initial treatment for men with low-risk disease and a life expectancy of less than 10 years and men with very-low-risk disease and a life expectancy of less than 20 years. Guidelines from the American Urological Association and European Association of Urology also recommend that active surveillance be considered among the first-line management approaches for clinically localized low-risk PCa. 

Active surveillance has the potential to spare thousands of patients the complications of radical surgery or radiotherapy (especially erectile dysfunction and urinary incontinence) that can adversely affect quality of life. Although data suggest that active surveillance is underused, this may change as confidence in this management strategy grows. Recent studies may bolster that confidence. For example, some investigations have identified biomarkers that can accurately distinguish between indolent and aggressive tumors, which could assist in risk-stratifying patients. Greater certainty of a tumor's indolence may translate into more confidence in active surveillance as a management strategy. New treatments that take patient care in a new and positive direction are a great thing, but so are the medical advances that help patients avoid jumping into treatment unless it is necessary.