Best practice in active surveillance for men with prostate cancer: a Prostate Cancer UK consensus statement.

OBJECTIVES:To develop a consensus statement on current best practice of active surveillance (AS) in the UK, informed by patients and clinical experts. SUBJECTS AND METHODS:A consensus statement was drafted on the basis of three sources of data: systematic literature search of national and international guidelines; data arising from a Freedom of Information Act request to UK urology departments regarding their current practice of AS; and survey and interview responses from men with localized prostate cancer regarding their experiences and views of AS. The Prostate Cancer UK Expert Reference Group (ERG) on AS was then convened to discuss and refine the statement. RESULTS:Guidelines and protocols for AS varied significantly in terms of risk stratification, criteria for offering AS, and protocols for AS between and within countries. Patients and healthcare professionals identified clinical, emotional and process needs for AS to be effective. Men with prostate cancer wanted more information and psychological support at the time of discussing AS with the treating team and in the first 2 years of AS, and a named healthcare professional to discuss any questions or concerns they had. The ERG agreed 30 consensus statements regarding best practice for AS. Statements were grouped under headings: 'Inclusion/Exclusion Criteria'; 'AS follow-up protocol' and 'When to stop AS'. CONCLUSION:Significant variation currently exists in the practice of AS in the UK and internationally. Men have clear views on the level of involvement in treatment decisions and support from their treating professionals when receiving AS. The Prostate Cancer UK AS ERG has developed a set of consensus statements for best practice in AS. Evidence for best practice in AS, and the use of multiparametric magnetic resonance imaging in AS, is still evolving, and further studies are needed to determine how to optimize AS outcomes

Sustainability in architectural regeneration

The term sustainability has been defined in many ways, discussed and criticised as a term that lacks clarity, but if the debate is put aside, the key concepts underlying the term are clear. Sustainability is about sustaining life in the long term and sustaining the life-support mechanisms that humans and other species rely on for survival. From a built environment perspective, designing for sustainability is equivalent to designing for longevity. This includes longevity of buildings, which need to be viable in the long term and resilient to the stresses of changing climates, and the longevity of ecosystems and natural life-support mechanisms. To achieve the latter requires a reduction of the anthropogenic impacts on these systems, and this is a fundamental aim of sustainability. Another fundamental aim is to achieve a high quality of life and wellbeing for people. Not only it is undesirable and could be described as unethical to aim for a lifestyle that lacks quality overall or where quality of life is unevenly distributed between individuals and communities, but longevity and quality are interdependent. From a built environment point of view, high quality environments are typically viable in the long term. Furthermore, to reduce the anthropogenic impacts on the environment, people will have to change their lifestyles. To motivate individuals to adopt sustainable lifestyles, the new sustainable lifestyle has to offer a high quality life if not a higher quality life than the previous one. Therefore, to create sustainable built environments it is essential to create high quality, socially, culturally and economically long-term viable developments that have minimal impact on the environment. Sustainability is multi-dimensional with technical, socio-economic, environmental, political and ethical implications, some of which can be quantified and others not. For instance, the ‘services’ provided by natural environments to society, such as purifying water and air, alleviating flooding and more, can be valued in economic terms (United Nations 1992; Girardet 2004; WWF 2014). The value of cultural activities is far more difficult to establish, as is balancing cultural customs and the natural environment when the former negatively impacts on the latter. Personal interests and ethics come into play when prioritising actions in relation to sustainability. However, there is now global consensus that addressing global warming and climate change resulting from greenhouse gas emissions is a global priority (United Nations 2015). The UK government, for example, has set a goal of an 80% reduction in carbon dioxide (CO2) emissions by 2050 from 1990 levels (UK Government 2008) in order to keep global warming within the 2°C believed to mitigate risks, impacts and damages (Meinshausen et al. 2009). Buildings in the UK account for nearly 47% of total CO2 emissions in the UK (DBIS 2010) and 40% of energy consumption in Europe (European Union 2010). Addressing climate change in conjunction with other environmental issues, such as resource depletion, pollution, destruction of biodiversity, as well as human health and well-being, requires technical solutions, many of which exist and are increasingly common. It also requires political and economic implementation mechanisms that, however, are often hampered by the human psychology, which can be characterised as conformist, ultimately self-interested, averse to perceived loss and change, and often subject to short term views (Cialdini 2008; Earls 2009; Kahneman 2012; Pratarelli 2012; Burns 2013; Kottler 2013; Dietz 2015). Sustainability requires a long term view and lifestyle changes, which may not appear attractive to many people and most are yet to become mainstream. As a result, progress towards a more sustainable society remains slow. The regeneration of buildings and settlements is more acutely affected by the challenges related to selecting and implementing sustainable strategies and solutions than new developments. Apart from the potential technical difficulties of working with existing environments, regeneration affects the socio-economic status of an area and a community. These socio-economic impacts need to be evaluated but accurate predictions can be difficult to make. For instance, the regeneration of a deprived area should create a higher quality of life for residents, but can also negatively impact on local communities who are out-priced once property prices increase. An understanding of the context and the impact that the development might have is essential to make informed decisions. Therefore, to be sustainable the regeneration of buildings or settlements has to be viable long-term and impact minimally on the natural environment, and this can only be achieved by first understanding the socio-economic and natural context and then developing solutions that respect it. Solutions have to be evaluated in terms of impacts (what is gained and lost) and feasibility (what is possible and what resources are needed to achieve the strategy). Designing for low carbon emissions throughout a development’s lifetime is a key priority, but other sustainability issues cannot be ignored. Nor can the human dimension that is pivotal in the implementation of sustainability