Laurence Klotz, MD, FRCSC

In the first part of a Platinum Lecture trilogy on active surveillance, Laurence Klotz, MD, Professor of Surgery and holder of the Sunnybrook Chair of Prostate Cancer Research at the University of Toronto, discusses the history of active surveillance for prostate cancer as well as current guidance for its implementation. He first notes the major issues in early prostate cancer in the present day, including risk assessment prior to diagnosis, diagnostic evaluation of localized disease, and image-guided partial gland ablation therapy. Dr. Klotz then looks back to early papers suggesting that radical treatment may be unnecessary and ineffective in treating low-risk prostate cancers, remarking on their influence on himself and his colleagues’ 2002 feasibility study on watchful waiting. He reflects on how active surveillance has become widely accepted since that publication, and discusses what urologists have learned regarding patient selection, especially in terms of molecular genetics. Dr. Klotz then compares different studies of active surveillance, focusing on one with broad patient selection criteria and one with conservative selection criteria. The study with broader patient criteria found a raw prostate cancer-specific mortality of 1.5% and an actuarial mortality of 5% at 15 years, while the more conservative study found a prostate cancer-specific mortality of 0.5% at 15 years. Dr. Klotz notes that the 5% actuarial mortality in the first study was determined to be largely the result of the presence of pattern 4 disease at baseline. He also observes that there has been a convergence of selection criteria since those studies came out. Dr. Klotz concludes by discussing current active surveillance protocol, emphasizing the importance of doing a confirmatory biopsy.