Active Surveillance

Active SurveillanceProstate cancer will affect one in seven men during his lifetime. As recent as 30 years ago, the majority of patients present with advanced incurable disease.   PSA testing and advances in prostate imaging and biopsy techniques have led to the earlier diagnosis of this cancer in the majority of men. As a result, many patients with prostate cancer have several suitable treatment options to consider.

Unlike many cancers, some prostate cancers tend to grow at a very slow rate. Men diagnosed with this type of prostate cancer may be managed with less invasive means, and, in some instances, treatment can be delayed or avoided altogether by using a protocol of active surveillance. This method requires that patients with low risk disease are followed closely using lab studies, physical examination, periodic imaging and repeat biopsy. Provided that certain criteria used to designate a prostate cancer as “low risk” are maintained, the patient may be able to avoid therapy and any therapy related side effects for prolonged periods of time. In the event of evidence of prostate cancer progression, treatment can be offered before the disease has the opportunity to spread beyond the prostate gland.

Candidates for active surveillance are those whose prostate cancer is detected early. Most protocols include patients with a PSA score of less than 10, a prostate cancer grading score (GLEASON GRADE) of less than 3+4, and a low volume of prostate cancer found at the time of the biopsies. Recently, favorable imaging of the prostate using MRI scanning is felt to also be an important component to the formula when deciding on the appropriateness of active surveillance. In a recent study, two-thirds of the men diagnosed with prostate cancer qualified for active surveillance. For many of these men with slow-growing prostate cancer, other cancer treatments, such as radiation or surgery, may not actually help them to live a longer, more comfortable life. These more invasive or aggressive options come with known side effects and risks that often outweigh the benefits.

Most men with prostate cancer who choose active surveillance will schedule doctor’s appointments every three to six months. At these checkups, the men will typically have a prostate-specific antigen (PSA) blood test and a digital rectal exam. With these two assessments, the doctor can provide updated information on any changes in the cancer. If the doctor has any concerns, they may also request a prostate biopsy to get more specific results. After testing is complete, if there are any significant variations in the cancer, the patient’s doctor may suggest further treatment options. Because some prostate cancers grow slowly and have a minimal likelihood of spreading, some patients who choose active surveillance may never need to utilize further treatment options during their lifetime.

The largest study comparing prostate cancer surgery with active surveillance published by the New England Journal of Medicine in 2012 showed that over a fifteen-year period, men who were diagnosed with early stage prostate cancer fared just as well with active surveillance when compared to radical prostatectomy.   Approximately one third of these patients developed signs of more aggressive disease and proceeded to have therapy at that time. In addition, a percentage of men find that active surveillance can become psychologically burdensome and therefore elect to proceed with less invasive but effective options for treatment.

Positive studies surrounding early prostate cancer diagnoses continue to come out. With early detection for many prostate cancer cases, active surveillance is an advantageous option. Instead of immediately removing the cancer, which comes with known side effects that can be detrimental to a patient’s overall quality of life, many patients are choosing to actively monitor their cancer and make the decision for more advanced treatment only when it is deemed necessary. Provided that close follow-up is maintained, many men never have to submit themselves to radiation or surgery.

Reviewed by Dr. John Jurige