Our Greatest Wealth Is Health

Andrew Siegel MD  7/13/2019

Yours truly in the operating room using my down time productively to write while waiting for a case to get into motion.  My motto is “always bring homework.”

Active Surveillance to Treat Prostate Cancer: What You Need to Know

Torse d’homme, 1934, Jules Desbois, Musee d’Orsay, Paris (photographed by my friend Angela Fornstrom)

The challenge for those of us who treat prostate cancer is to predict the behavior of the cancer to treat it appropriately—offering curative treatment to those with aggressive cancer but sparing the potential side effects of curative treatment in those who have non-aggressive cancer. “Active surveillance” is the strategy of careful monitoring of non-life-threatening, low risk prostate cancers. The goal of active surveillance is to avoid active treatment of prostate cancers that do not have lethal or metastatic potential.

“To do nothing, that’s something.”   Samuel Shem, The House of God

“If there is no difference in mortality (between active surveillance and immediate treatment), then quality of life is the defining issue.”  Mark Litwin, MD, MPH, Chairman of Urology, UCLA School of Medicine

The ratio of lifetime likelihood of diagnosis of prostate cancer (about 1 in 9 men) to death from prostate cancer (about 1 in 40 men) points to the fact that many men with prostate cancer have indolent (slow growing) cancers. On this basis, an alternative strategy to aggressive management of all men with prostate cancer is for careful follow-up, reserving curative intervention for if and when signs of progression develop.

Active surveillance involves rigorous monitoring and the willingness to have regular follow-ups. In addition to its utility for men with non-aggressive cancer, it is also appropriate management of prostate cancer in older men or those with serious health conditions. Active surveillance was introduced in the mid-1990s and has gradually gained traction to the extent that we are now in the “era of active surveillance.”

Eligibility criteria for active surveillance are the following (note that these are general guidelines and are modified in accordance with patient age, general health and other factors— certainly if one has a life expectancy of less than 10 years, he would be a good candidate for active surveillance):

• Prostate Specific Antigen (PSA) less or equal to 10
• Gleason score 6, although active surveillance is occasionally used for low-volume Gleason 7 (3+4) cancer (Note that although some experts do not think that the term “cancer” is appropriate for Gleason 6 disease, recent studies have shown that a small percentage of men with Gleason 6 can potentially have local extension beyond the prostate, supporting the argument for continuing to use the term cancer for these tumors.)
• Stage T1c-T2a
• Less than 3 cores with cancer
• Less than 50% of any one core involved
• Genomic testing confirming low risk for progression is an additional tool that can help guide eligibility

A general guide to the monitoring schedule is the following:

• PSA and DRE every 6 months
• Repeat biopsy (“confirmatory biopsy”) one year following initial diagnosis, then periodically thereafter (I prefer annual biopsies for the first 3 years)
• Prostate MRI (not a substitute for repeat biopsy, but once serial biopsies have confirmed low risk cancer, can be used periodically in lieu of prostate biopsy)

Serial PSA levels are invaluable for men on active surveillance. PSA doubling time (PSADT)—the amount of time it takes for the PSA to double—is an excellent means of predicting prostate cancer behavior.  A short PSA doubling time is usually indicative of an aggressive, rapidly growing tumor, whereas a long PSA doubling time is indicative of an indolent, slower growing tumor. A PSADT of less than 3 years is clearly associated with the potential for progression of prostate cancer.

The repeat biopsy is the most important component of the active surveillance protocol.  There are three possible outcomes to follow-up biopsies: cancer-free, stable low risk cancer, and worsening cancer. A cancer-free pathology report is usually indicative of an excellent prognosis, insofar as the absence of cancer on repeated prostate biopsy (because the cancer is of such low volume) identifies men who are unlikely to have progressive prostate cancer.  It does not mean that cancer is no longer present but implies that the cancer is extremely low volume and that the original biopsy discovered the “needle in the haystack.” Stable low risk cancer is consistent with the original biopsy in terms of tumor volume and grade and indicates that the active surveillance protocol may be continued, sparing the patient the potential side effects of surgery, radiation or other modalities. Worsening cancer is demonstrated by a higher Gleason score or increased tumor volume as indicated by number of cores and percentage of tumor involvement per core. A higher Gleason score, increased tumor volume or a PSADT of less than 3 years will often result in a reclassification requiring a change in plan to active management with curative intent.

65-75% or so of men on active surveillance remain free of progression at five years, and definitive treatment is usually effective in the 25-35% who progress or elect active treatment for another reason.

Advantages of Active Surveillance:

• Avoids side effects and complications of immediate treatment
• Minimizes over-treatment of indolent prostate cancer
• Low cost

Disadvantages of Active Surveillance:

• Need for frequent and repeated testing and biopsies
• Anxiety of living with untreated prostate cancer
• Imprecise criteria for delayed intervention
• Delayed treatment may ultimately need to be more aggressive (with more potential side effects) compared to earlier intervention
• Delayed treatment may not be curative or as effective as earlier intervention

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Tags: active surveillance, Andrew Siegel MD, non-aggressive low-risk prostate cancer, prostate cancer, Prostate Cancer 20/20

This entry was posted on July 13, 2019 at 7:09 AM and is filed under health and wellness. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.