Active Surveillance for Prostate Cancer

Refined over the past 25 years, active surveillance is now recommended for managing low risk and favorable cases of intermediate risk prostate cancer. This strategy involves monitoring prostate cancer progression by prostate-specific antigen (PSA) testing and physical examinations. With prostate cancer known to be a slow-progressing cancer in its early stages, this method has proven to be a much safer way of managing the cancer, rather than charging head-first into the battlefield.

Unfortunately, this hands-off approach may make you or those close to you feel uneasy. Rest assured, while there is limited intervention at this stage, your cancer will still be carefully monitored on a regular basis. Strong indications of progression will be caught as soon as possible, and your doctor will be able to consider a transition to actively treating the tumor at that point.

The key benefit of going through all this trouble is to avoid the pain, hassle and discomfort associated with other therapeutic interventions (e.g. surgery, chemotherapy or radiotherapy), especially if not yet necessary. It is completely possible that your cancer may take a long time to advance to the point of being life-threatening, with a 5-year survival rate of 97% in the US. Additionally, with the introduction of early detection by PSA screening and advances in treatment, the risk of death from prostate cancer in the US has declined by 53% since 1993.

The safety of active surveillance has also been demonstrated in large clinical trials, highlighting that those with low risk prostate cancer can postpone treatment without worsening their odds of cancer progression or risk of death.

At the start, your doctor will work to confirm your suitability for active surveillance by carrying out a few more tests. Magnetic resonance imaging (MRI), physical examination and biopsy may be recommended to confirm that no high-risk tumor tissue present in other parts of your prostate was missed during your initial diagnosis test.

Following that, the current National Comprehensive Cancer Network (NCCN) recommendations for active surveillance are as follows:

• Blood tests to measure your PSA values every six months at most
• Symptom evaluation and physical rectal exam on a yearly basis at most
• Biopsy every one to four years
• MRI on a yearly basis at most

This testing schedule can also be personalized by your doctor according to your particular case, and the intensity of your follow-up schedule may be tailored based on your risk of progression.

If your PSA level goes up during one of your regular blood tests, there is no cause for alarm yet as fluctuations in your PSA level are common. It will be tested again, and if it does repeat, your doctor will likely recommend an additional MRI scan and possibly a biopsy in order to decide if there is a need to consider conversion to active treatment.

According to the NCCN, the best candidate for active surveillance will have low risk prostate cancer, recognized by the following features:

• PSA level <10 ng/mL,
• Grade Group 1, and
• Clinical stage T1–T2a

Alternatively, if advised well, those facing intermediate risk cancer with a likely favorable outcome can still be considered for active surveillance as an option. This includes:

• Grade Group 1 with a PSA level of 10 to <20 ng/mL or clinical stage T2b–c and <50% positive biopsy samples or
• Grade Group 2 with a PSA level of <10 ng/mL and clinical stage T1–2a and <50% positive biopsy samples

However, active surveillance should only be recommended for those expected to live long enough to enjoy quality-of-life improvements from active treatment.

Simply put, sometimes doing nothing is better than making matters worse. Treatments for cancer are typically known for their adverse side effects and the mental toll it takes on patients. Out of those with prostate cancer that has yet to spread, those who received active treatment generally report a poorer quality of life. For example, those treated with surgery reported more issues with urination and sex, while those treated with external beam radiotherapy, report more bowel issues.

Given the low risk of death for those diagnosed with early prostate cancer, doing too much too early may put you at risk for suffering beyond what is necessary.

Going forward, current guidelines now suggest that active surveillance is a necessary standard of care for low risk prostate cancer. There is also hope that MRI scans or biomarker tests could eventually replace the required biopsies as well, reducing the overall discomfort necessary. With the latest and thoroughly investigated strategy for managing your cancer, you can rest assured that your future will be in good hands.