Interventions for patients with prostate cancer on active surveillance: a narrative review

Objective To examine contemporary evidence supporting non-surgical interventions for patients with early prostate cancer (PCa) on active surveillance (AS).

Methods A literature search was conducted using the databases PubMed, Medline, and Embase in January 2024 to identify relevant articles published from 2011 onwards. Randomised controlled trials (RCTs) and cohort studies reporting on interventions in patients with PCa on AS were included.

Results Several studies have investigated a range of non-surgical interventions, from exercise and food supplements to androgen receptor pathway inhibitors (ARPIs). The largest RCTs of ARPIs have shown the greatest effect in delaying disease progression to aggressive PCa, however, concerns exist around toxicity, long-term oncological safety, and mortality benefit. Nutraceuticals, dietary modifications, and exercise appear to be well tolerated, but evidence of oncological benefit from large-scale RCTs is lacking. A major challenge is the lack of consensus on criteria for entry to and exit from AS as pre-biopsy magnetic resonance imaging reduces diagnosis of the lowest-risk disease. Molecular and imaging biomarkers may help refine baseline risk stratification and guide monitoring during surveillance.

Conclusion Current evidence supporting interventions for patients on AS remains largely based on small prospective cohort studies or open-label phase II trials. There is growing interest in short-term ARPIs for patients at higher risk of disease progression, while nutraceuticals, diet and exercise may have a role for long-term use in lower-risk patients. Large, well-powered RCTs with long-term outcomes testing different interventions and incorporating molecular and imaging biomarkers are warranted.