Is Active Surveillance Right for You?

“Prostate cancer” and “good news” are two phrases that generally don’t go together in the same sentence. Like all silent killers, prostate cancer is insidious—but we are smarter. Over the past decade, huge strides in awareness, routine PSA testing and early detection mean there is good news when it comes to prostate cancer.

“Today, men who are diagnosed with prostate cancer generally have much smaller, lower-grade, slower-growing tumors,” says Richard Bevan-Thomas, M.D., director of USMD Prostate Cancer Center (PCC). “Ten to 20 years ago, about one-third of men diagnosed with prostate cancer already had metastatic cancer that had spread to their bones or lymph nodes by the time they were diagnosed. But now, that number is just one or two percent. Because we are diagnosing more men in the very early stages of prostate cancer—many times long before they even have any symptoms of the disease—active surveillance is often a prudent first step in their treatment.”

What exactly is active surveillance? It is a practice that has evolved out of another term—watchful waiting. Rather than immediately undergoing surgery or radiation treatments that can have unwanted side effects such as incontinence and erectile dysfunction, patients are monitored for a period of time. But unlike “watchful waiting,” this watch isn’t a passive period where patients and physicians wait for symptoms to signal a progression of the disease.

“During active surveillance, we like to see patients every three to six months,” says Justin Lee, M.D., a board-certified urologist and surgeon with USMD PCC. “During these visits we conduct a variety of tests to actively track the patient’s cancer so we can determine if there has been even the smallest change or progression in their cancer.”

Active surveillance tests may include one or more of the following:

  • Digital rectal exam every six months to feel the prostate and determine if the cancer has grown

  • Prostate-specific antigen (PSA) every three to six months to measures the amount of prostate-specific antigen in the blood. A rise in a patient’s PSA level may indicate cancer growth

  • Transrectal ultrasound-guided prostate biopsy performed at one-year and two to three-year intervals to collect a sample of cells from within the prostate to detect any changes in the patient’s Gleason score and cancer staging

“What we look for with these tests are abnormal changes in PSA levels, a change in tumor volume based on ultrasound imaging or biopsy, and a change in cancer grade or stage based on a biopsy,” Dr. Bevan-Thomas says. “We are also beginning to use genetic testing for these cancers to give us another view of the patient’s risk of progression. If results from any of these tests indicate that the disease may be progressing, then more aggressive treatment such as radiation, surgery or cryoablation is started.”

While some men may feel nervous about not immediately pursuing a more aggressive treatment course from the get-go, research shows that men who are good candidates for active surveillance and who opt to participate in it as a first step in their treatment have outcomes that are just as good as men who undergo radiation or surgery right away. In fact, a study published in the June 2013 issue of the Annals of Internal Medicine reported that “observation is a reasonable and, in some situations, cost-saving alternative to initial treatment for the estimated 70 percent of men whose cancer is classified as low-risk at diagnosis.”

A clinical trial—called PIVOT—reported that men who underwent active surveillance had about the same small risk of death over a 12-year period whether they underwent radical prostatectomy or observation.

Regardless of the statistics, deciding whether or not to pursue active surveillance or a more aggressive form of treatment is “really a personal choice,” Dr. Lee says. “Every patient is different. Not all patients have the same types of cancer tumors with the same grade. Only you and your physician can determine whether active surveillance is a good option for you.”

Active surveillance may be right for you if:

  • Your cancer is detected early while it's still small and limited to one area of your prostate.

  • Your Gleason score is low—6 (3+3) or less—which indicates your cancer is a less aggressive, slower-growing cancer.

  • You have other advanced health problems that could be made worse during treatment for prostate cancer.

  • You are older and aggressive prostate cancer treatment is less likely to extend your life expectancy.

Of course, there are some risks with active surveillance. You cancer can grow and spread while you wait. PSA testing used to help monitor your cancer during active surveillance isn’t a perfect test. Some cancers spread before PSA levels rise and signal a problem. If your cancer spreads during active surveillance, you could miss the window for effective treatment. Finally, the uncertainty associated with active surveillance may make you feel anxious or stressed—which can have an adverse effect on your immune system. These are all important factors to consider before you decide to undergo active surveillance.

“Perhaps the most important aspect of active surveillance is the possibility that we may need to treat these patients more aggressively in the near future.” says Dr. Bevan-Thomas. “Roughly thirty to forty percent of patients will either request or need an intervention for their cancer within the first five years of active surveillance. We are looking for that sweet spot between undertreating and overtreating prostate cancer, while still keeping the risk low for these patients. If we do see signs of progression, then we need to be more aggressive with these cancers.”

If you or a loved one have been diagnosed with prostate cancer and would like to know more about active surveillance, talk with one of the board-certified urologists at USMD Prostate Cancer Center.

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