Health Outcomes Research Factors That Influence Patient Enrollment in Active Surveillance for Low-risk Prostate Cancer Michael A. Gorin, Cynthia T. Soloway, Ahmed Eldefrawy, and Mark S. Soloway OBJECTIVES To learn from patients their rationale for enrollment in active surveillance (AS) for low-risk prostate cancer as an alternative to primary treatment. METHODS A rank-order survey was designed to assess the relative influence of factors that contributed to the decision to elect AS. The survey was mailed to 185 patients enrolled in AS at our university-based urologic oncology practice. Participants were also asked whether they had been offered AS as an alternative to primary treatment by the urologist who had initially diagnosed their cancer. RESULTS The survey was returned by 105 (57%) of 185 patients. AS was offered to 38 (36%) of 105 patients by the physician who had made the initial diagnosis. Patients most frequently reported physician influence as the greatest contributor to their decision to elect AS (73%). Patients also cited concerns regarding the potential side effects of incontinence (48%) and erectile dysfunc- tion (44%) associated with therapy as reasons for choosing AS. CONCLUSIONS The results of the present study have shown that patients are heavily influenced by physicians in their decision to elect AS. Notably, the majority of our sampled patients were not offered AS at diagnosis. Evidence has indicated that AS is an appropriate approach for low-risk prostate cancer and should be discussed with patients in this risk category. UROLOGY 77: 588 –591, 2011. © 2011 Elsevier Inc. T he American Cancer Society estimated that in 2009, nearly 192 000 new cases of prostate cancer (PCa) would be diagnosed. 1 This represents an incidence of nearly 25% of all cancer found in American men. Of these new cases, approximately 70% will be low-grade, low-stage tumors, 2 the majority of which will be treated with either surgery or radiation therapy. 3 Both of these treatments have been associated with significant negative quality-of-life sequelae. Therefore, it is impor- tant to consider alternatives to these treatments, because it has been estimated that only 2-3% of men with low- risk disease will die of PCa. 4,5 Active surveillance (AS) of low-risk PCa has emerged as a viable alternative to surgery and radiation thera- py. 4-10 AS involves monitoring the patient at specified intervals for signs of progression (ie, changes in tumor volume or grade). AS is particularly appealing in that it reduces overtreatment and allows for intervention at evidence of progression. This is based on the assumption that progression can be identified by prostate-specific antigen (PSA) measurement and biopsy. However, lim- itations exist in precisely defining tumor grade and clin- ical stage. 11,12 A well-informed decision and good patient compliance are critical for a favorable outcome. Our data have suggested that AS is a safe strategy for the management of low-risk PCa. We observed a 100% PCa- specific survival at a mean follow-up of 45 months. 7,10 Moreover, at 5 years, 85% of patients had remained free of disease progression without treatment. Similarly, other large series have found that the 10-year PCa-specific survival rate approaches 98%. 4,5 It has been estimated that the risk of dying of other causes during AS is 18.5 times greater than PCa-specific mortality. 4 In light of these and other similar findings, guidelines from the National Comprehensive Cancer Network and European Association of Urology recommend AS for patients with low-risk PCa as an alternative to primary treatment. For most patients, the decision to enroll in AS is difficult. Frequently, this decision is a collective one involving the patient, family, and physician. Therefore, several factors, such as education about the available treatment options, family support, and physician bias can influence a patient’s decision to enroll in AS. It is im- portant for physicians to understand the relative influ- ence of these factors in the decision-making process. The From the Department of Urology, University of Miami Miller School of Medicine, Miami, Florida Reprint requests: Mark S. Soloway, M.D., Department of Urology, University of Miami Miller School of Medicine, P.O. Box 016960 (M-814), Miami, FL 33101. E-mail: msoloway@med.miami.edu Submitted: August 17, 2010, accepted (with revisions): October 20, 2010 588 © 2011 Elsevier Inc. 0090-4295/11/$36.00 All Rights Reserved doi:10.1016/j.urology.2010.10.039