General application of the National Institute for Health and Clinical Excellence (NICE) guidance for active surveillance for men with prostate cancer is not appropriate in unscreened populations



We read with great interest the retrospective study by Wong et al [1] about the validity of applying NICE guidance in the management of men with low-risk prostate cancer. Namely, whether active surveillance (AS) was an appropriate primary recommendation in men diagnosed with low-risk disease in an unscreened population. The authors caution against AS after finding that about one-third of men with ‘low-risk’ disease on TRUS-guided biopsy were found to have more advanced disease in the prostatectomy specimen.

However, we have some concerns about the conclusions drawn. First, the findings are not new and have been replicated in screened and unscreened populations. Second, this is not surprising, as TRUS-guided prostate biopsies, a rather antiquated form of ‘random biopsies’, is far from the ‘gold standard’ for characterising prostate cancer that many wish it to be. It has serious flaws whether applied in the UK or North America. Both upgrading and downgrading of disease occur and risk categories based on TRUS-guided biopsy parameters have poor predictive abilities [2]. Third, with tools at our disposal to overcome poor risk stratification, template mapping biopsies combined with multi-parametric MRI, we can risk stratify prostate disease more accurately. The ability to map the gland in a formal, reproducible manner, allows clinicians to detect areas of significant disease, and monitor (or potentially discount) insignificant disease [3]. In this way, the clinician and patients can make more informed choices about the management of their disease. The UK has been at the forefront of increasing the use of AS [4] and we can continue to lead in this field. We congratulate the authors of this study, as it highlights that as UK urologists, we should be delivering best practice to our patients, and leave TRUS-guided biopsies to the history books.