Prostate Cancer Active Surveillance

All forms of treatment for localized prostate cancer seek to balance the risks of the cancer against the risks and benefits of treatment in order to maximize both quantity and quality of life.

 

Active Surveillance is a treatment approach that acknowledges that in some men the prostate cancer is not currently life threatening and, in fact, may never cause the patient a problem. Active surveillance also acknowledges that surgery and radiation provide little to no benefit in terms of survival to men with low risk prostate cancer but can cause undesireable side effects such as urinary incontinence, erectile dysfunction, and rectal bleeding. Stated another way, in some circumstances there are likely to be few if any benefits to radiation or surgery but a definite potential for side-effects – therefore the risks of treatment are likely to outweigh the risk of the prostate cancer itself.

 

Important points about active surveillance:

 

  1. Candidates for active surveillance must be properly selected based on the characteristics of the disease and a man's tolerance for this treatment approach.
  2. Active surveillance is the treatment of choice for many men. That is, active surveillance is NOT just relegated to those men unsuitable for radiation or surgery. Do not assume that you are being offerred active surveillance because you are unfit or felt to have shortened life expectancy.
  3. It is not the same as 'watchful waiting'. Watchful waiting is a palliative treatment approach that recognizes that a man has such a short life expectancy because of other health issues that treatment should only be undertaken if symptoms are present.
  4. Most men on active surveillance protocols never progress to the point that the prostate cancerwarrants treatment. Stated another way, men are likely to remain free from any effects of the cancer (and get to avoid the side effects of radiation and surgery).
  5. In deciding to take an active surveillance approach, a man agrees to a surveillance protocol

 

Advantages of Active Surveillance Disadvantages of Active Surveillence
  1. avoid side effects of definitive therapy that may not be necessary
  2. maintaining quality of life and normal activiteis
  3. minimizing the risk of unnecessary treatment for small, indolent cancers
  1. possibilty of missing an opportunity for cure
  2. possibility of progression or metastasis of the cancer before treatment
  3. increased difficulty in the treatment of more aggressive cancer with greater side effects
  4. increased anxiety of living with untreated cancer
  5. need to examine and undergo repeat prostate biopsy


 

Surveillance Protocols

 

The purpose of active surveillance to ensure as best as possible that the cancer has not changed in a way that might jeopardize a man's quality or quantity of life. The nature of the surveillance protocol can be tailored to the individual (just like radiation and surgery are tailored) in a way which recognized their level of risk (not all men on active surveillance are the same) and their point in the journey (e.g. men with stable assessments over several years may not require the same intensity as a man just entering the process).

 

In every case, the surveillance protcol will involve the following components:

  1. PROSTATE EXAM twice yearly with Urologist
  2. PSA twice yearly
  3. PROSTATE BIOPSY usually every couple of years
  4. Investigational: 
    1. MRI (and MRI targeted biopsy): experimental at this time. Preliminary studies show that it may be helpful in a subset of men but probably of limited benefit in most men.
    2. Genetic testing, Circulating tumor cells (CTCs): no defined role
    3. PCA3: proven NO benefit

For the majority of men on active surveillance, this means:

  1. PSA and prostate exam TWICE A YEAR with urologist
  2. Confirmatory biopsy within 6-12 months of the initial diagnosis
  3. Prostate biopsy EVERY COUPLE OF YEARS

This sort of protocol may differ slightly between different medical centers but the fundamentals are the same: repeated risk assessment and determining if a transition to radiation or surgery is warranted.

 

The most important test (by a very large margin) in active surveillance is the surveillance biopsy.

 

A change in the pathology report is the single most common reason for men to transition from active surveillance to radiation or surgery - either an increase in the grade of the tumor or an increase in the volume of tumor. The PSA and DRE are essentially 'backstops' or safety checks that occur between surveillance biopsies. If either of these change, proceeding with an earlier unscheduled biopsy may occur. 

 

Who Is a Canadidate for Active Surveillance?

 

Only men with what are categorized as "very low risk" or "low-tier intermediate risk" prostate cancers are candidates for active surveillance. Note that not all men who are categorized as such should undergo active surveillance as the treatment needs to be individualized. To be categorized as low or low-tier intermediate risk a man should have:

  1. PSA less than 10
  2. Gleason 3+3=6/10 OR Gleason 3+4=6/10 on their biopsy
  3. 'Low volume' of cancer (lower number/% of total cores; lower % of core involvement - there is no real consensus here though most specify less than 3 cores and less than 50% of any one core)
  4. Stage T2 or lower (confined to the prostate)

 

If you meet these criteria, then active surveillance is likely to be an option for you. These criteria may be relaxed if you have significant comorbidities with a life expectancy of less than 10 years. Conversely, if you are very young (less than 55) the criteria should be more strict as the time horizon may be much longer than 15-20 years.

 

Ultimately, emotional aspects play a large role and you should have the mindset that you:

  • Have the ability to live with cancer without worry reducing the quality of life (i.e. you won't be stressed out thinking you should be having radiation or surgery)
  • Are most concerned about the potential side effects of radiation or surgery
  • Value near term quality of life to a greater extent than any long term consequences that could occur

 

Overall, in the US and Canada about half of all men under the age of 70 who are candidates for active surveillance choose this option.

 

What are the chances of dying if I go on active surveillance? 

 

Men are often surprised that a cancer would be 'watched'. A natural response if to 'cut it out' based on the assumption that all cancer kills. This is not the case for all prostate cancers. Prostate cancer can most definitely be lethal - about 3% of men ultimately die from prostate cancer, the vast majority of men with metastatic prostate cancer die within 5 years of diagnosis and up to half of all men with high risk localized cancer can die from cancer without treatment. Having said that, a large majority of men who receive a diagnosis of prostate cancer do not die from prostate cancer and are far more likely to die of another cause. For men with low or low-intermediate prostate cancer, the prognosis looks like this (the following data are from Johns Hopkins and University of California San Francisco):

 

  • About 3% of men on active surveillance protocols are expected to die from prostate cancer 20 years after diagnosis (and virtually no one within the first 5-10 years) compared with 1.6% of men who undergo immediate surgery.
  • 3.4% of men on surveillance vs. 2.0% of men undergoing immediate surgery would die of prostate cancer during their lifetime
  • The average projected increase in life expectancy attributed to surgery was 1.8 months
  • Men on surveillance would, on average, remain free of treatment for an additional 6 years

 

The outcome from active surveillance programs relfects a complex interaction of cancer risk, surveillance approach and overall patient health.

 

What are the chances of finding something that would warrant radiation or surgery?

Finding something that promptes definitive treatment is known as 'disease reclassification'. Because men on active survillance are already in the lowest risk groups, the risk reclassification is always upwards.

 

  • 1 in 3 patients will be reclassified within 5-10 years of diagnosis - virtually all of these men receive definitive treatment with radiation or surgery.
  • Reclassification tends to occur early on - a majority within the first few years after diagnosis and as a result of a biopsy (as opposed to PSA or prostate exam)
  • In most cases, the likely cause of the reclassification is increased sampling (i.e. more cores of tissue available for analysis, therefore a more complete assessment) rather then actual progression in the disease