Andrew Siegel MD 1/16/2021
Prostate cancer can be described through an analogy using birds, rabbits and turtles in a barnyard, the animals representing prostate cancers with different degrees of aggressiveness and the barnyard representing the prostate. The birds can easily fly away, designating the most aggressive cancers, the ones that have often spread by the time they are detected and are often not amenable to cure. On the other hand, the turtles crawl very slowly, exemplifying non-lethal cancers that can often be managed with active surveillance. The rabbits are the intermediate group that can hop out at any time, illustrating potentially lethal cancers that would likely benefit from treatment, the type of cancers that can be cured.
The bottom line is that prostate cancer encompasses a broad range of biology and clinical risk and its management needs to be tailored to balance the risk of disease progression with the risks of treatment. The great challenge for those who treat prostate cancer is to accurately predict the behavior of the cancer so as 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 non-life-threatening, low risk prostate cancers, the goal of which is to avoid active treatment of prostate cancers that do not have lethal or metastatic potential, reserving curative intervention for if and when signs of progression develop. How has this worked out so far? Read on
“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
GLEASON SCORE 6 PROSTATE CANCER
Gleason score (GS) 6 is the lowest grade cancer in the Gleason scoring system, which ranges from 6-10. Metaphorically, GS 6 is considered to be a slow-moving turtle.
A number of years ago, GS 2-5 cancers were considered malignant, but subsequently these were downgraded to being thought of as non-cancers. While GS 6 meets the histologic (microscopic) criteria of cancer, it does not meet the clinical (how it presents with symptoms and signs) definition of cancer because it rarely extends locally beyond the confines of the prostate, spreads to remote sites, or kills. Although debatable and highly controversial, some urologists no longer consider Gleason 6 to be a cancer and feel that GS 6 should be reclassified as a non-cancer (as it was done for GS 2-5).
ACTIVE SURVEILLANCE FOR PROSTATE CANCER
Active surveillance involves rigorous monitoring and regular follow-ups. In addition to its use for men with non-aggressive cancer, it is also appropriate for older men with prostate cancer or those with serious health conditions. The advantages of active surveillance are avoiding over-treatment of indolent prostate cancer as well as side effects and complications of immediate treatment. Disadvantages are the need for frequent and repeated testing and biopsies, the anxiety of living with untreated prostate cancer (“anxious surveillance”), imprecise criteria for delayed intervention, and the fact that delayed treatment may need to be more aggressive (with more potential side effects) compared to earlier intervention, and may not be curative or as effective as earlier intervention.
OUTCOMES OF ACTIVE SURVEILLANCE BASED ON A FEW RECENT STUDIES
Long-term follow-up of active surveillance at Memorial Sloan Kettering Cancer Center was recently reported in the Journal of Urology (Carlsson et al, Vol 203, pages 1122-1127). Of the > 2500 men with Gleason score (GS) 6 prostate cancer, the risk of metastasis at 5, 10 and 15 years was 0.1%, 0.6% and 1.5%, respectively. The risk of progression from GS 6 to a higher grade at 5, 10 and 15 years was 24%, 36%, and 41%, respectively. The percentage of men who remained on the active surveillance protocol at 5, 10 and 15 years was 76%, 64% and 58%, respectively. The overall 10-year survival of men with GS 6 cancer was 94%, with only one patient dying of prostate cancer and the other deaths on the basis of other competing medical issues. Of the > 500 men who proceeded to treatment, the majority underwent prostatectomy or radiation therapy, with a small percentage choosing androgen deprivation therapy or focal therapies.
Another study recently reported in the Journal of Urology (Ahmad et al, Vol 204, pages 476-482) from Princess Margaret Cancer Center in Toronto demonstrated that the time on active surveillance of men with low-risk prostate cancer does not compromise the window of curability, since the pathological and oncological outcomes in patients who underwent prostatectomy for grade progression after a period of time on active surveillance were similar to matched controls undergoing immediate prostatectomy.
Another recent study reported in the Journal of Urology (Lonergan et al, Vol 204, pages 1216-1221) from the Helen Diller Family Comprehensive Cancer in San Francisco concluded that 4 factors predicted biopsy reclassification to more aggressive disease: Percentage of positive biopsy cores; genomic score; PSA density (PSAD); and PSA kinetics. Percentage of positive biopsy cores refers to the extent of cancer involvement of the biopsy core that can range from 1%-100% with the greater the percentage of involvement, the higher the risk for reclassification. Genomic prostate score refers to the Oncotype DX biomarker tool with the higher the score, the greater the risk for reclassification. PSA density refers to the PSA divided by prostate volume and when 0.15 or greater was found to elevate the risk for reclassification. PSA kinetics refers to the PSA velocity, the change in PSA over time, with the greater the PSA acceleration over time the higher the risk for reclassification.
A final recent study reported in the Journal of Urology (Wang et al, Vol 204, pages 1229-1235) from the National Cancer Institute in Bethesda concluded that MRI (magnetic resonance imaging) can be used to predict progression and reclassification. The risk of progression and reclassification occurred in tandem with the PIRADS scoring system, the higher the PIRADS score at baseline, the greater the risk.
Bottom Line: Long-term follow-up has demonstrated that active surveillance is a safe and effective strategy for appropriately selected men with low risk prostate cancer. It avoids the morbidity of active treatment and if progression occurs, the delay in treatment does not compromise outcomes.
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. Today’s entry is excerpted from his latest 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 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
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, prostate cancer, Prostate Cancer 20/20
Our Greatest Wealth Is Health 
January 16, 2021 at 9:08 AM |
I am happy to know that low risk active survalence is becoming more acceptable as a way of treatment. Although close monitoring must be emphasized. I myself never having a rectal exam look for that ever looming jump in PSA, And fervent about not wanting a prostate biospy for the classification of this disease. Nevertheless I would fully except the MRI procedure. My question is to get to the active survalence monitoring is an MRI definitive enough for G6 or lower or must a biopsy inevitably be the only way to classify Gleason score to obtain “active survalence “status.
January 17, 2021 at 12:52 PM |
First, you should have a digital rectal exam (DRE). It is entirely possible to have a prostate cancer that is picked up via an abnormal exam with an absolutely normal, even low PSA. While DRE, PSA and MRI are all helpful tests, the ONLY definitive test is the biopsy. “The buck stops here” with the biopsy.
January 16, 2021 at 12:29 PM |
“active surveillance is a safe and effective strategy for appropriately selected men with low risk prostate cancer. It avoids the morbidity of active treatment”
So hundreds of thousands of men have been maimed for life for no good reason. This is another terrible example of medical reversal: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238324/
The medical profession deserves the horse’s ass award for this.
January 17, 2021 at 1:02 PM |
The morbidity of unnecessary surgery is unfortunate, but I disagree with you about the medical profession. Back then, we did not have the wherewithal to accurately assess and predict risk, so all prostate cancers were treated with surgery and radiation. A major advance in the last few decades is the vast improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach.