Is Active Surveillance for Prostate Cancer Right for You?
NOVEMBER 01, 2015
Ten years ago, when a routine procedure for another issue revealed prostate cancer, Steve Berry thought, “this is kind of crazy.” But, because of his extensive background in reproductive physiology research, he was well-acquainted with his options and the known progression of this disease.
“I wanted to avoid radiation and I knew the numerous side effects that were possible with radical prostatectomy,” Berry says, “so I talked with my doctor and, based on everything we knew about my cancer at the time, we decided to wait and keep an eye on it.”
Like Berry, more and more often, men diagnosed with low-grade prostate cancer are choosing to defer treatment, preferring to monitor the status of their cancer by having regular blood tests and tissue biopsies that are designed to let them know if they need to be treated or if they can continue to hold off.
This approach is called "active surveillance."
“There’s a part of me that couldn’t help but wonder if I was just throwing the dice,” says Berry. “But over the 10 years, there has been no change in the size of the prostate and with continued monitoring there has been no change in my blood tests that check for cancer.”
“Prostate cancer doctors here at Beth Israel Deaconess Medical Center pioneered active surveillance at a time when the approach was considered experimental,” says Peter Chang, MD, MPH , Director of the Prostate Cancer Center at BIDMC. “Our studies have helped make it clear that for the right patient, active surveillance is not only safe, but can save men from years of treatment-related side effects.”
A recent study done by doctors at BIDMC shed more light on which prostate cancers are more likely to progress and which can be safely monitored.
"Active surveillance is the most up and coming strategy available to patients who are realizing they can have prostate cancer and not necessarily have it treated if their tumor is low grade," says William C. DeWolf, MD , senior author and Chief of the Division of Urologic Surgery at BIDMC. "We're trying to save quality of life. But in order to do that, we have to know how to predict if you are a good candidate or not. When you have cancer, you want to know your odds. Does it have to be treated or can it be left alone?"
In the study, 135 men with low grade tumors were followed for as long as 10 years.
Risk factors for those who saw their cancer progress were those with a family history of prostate cancer or those with elevated PSA density or a PSA that is rising quickly over time. The PSA test is a blood test that measure levels of a protein linked to prostate cancer. A high PSA level is often the first indication that there may be a problem. PSA density measures the level of the protein in relation to the size of the prostate itself. It is derived by dividing the PSA number by the gland volume in cubic centimeters (ccs).
"We found as they entered the study if they did not have a family history and had a PSA density of less than .08, the odds of progressing would be around 30 percent over eight years,” says DeWolf.
"We are using this information to personalize therapeutic decisions as best we can," says Glenn Bubley, MD, Director of Genitourinary Oncology at BIDMC and a co-author of the study that was published in the Journal of Urology. "We can give the patient some sense of what his risk of progression might be."
Many men with prostate cancer don't want to be treated if they don't have to, because the treatments carry a high risk of impotence or incontinence.
Co-author Marc Garnick, MD, an oncologist specializing in prostate cancer at BIDMC and editor of the Harvard Medical School Annual Report of Prostate Diseases, says most men can confidently wait.
"The bottom line is that two-thirds of men who have prostate cancer with certain characteristics can go long periods without being treated or they may never need to be treated," Dr. Garnick says. "I've had a patient on active surveillance for 16 years."
That’s what Berry is hoping for. Still, he gets PSA tests on a regular basis, biopsies periodically and scans between biopsies.
“For me, and I’m sure for a lot of men, it certainly makes sense to wait and see what’s going on,” he says. “But, if we discover something that indicates that it might be growing or becoming a problem, I’ll probably choose the surgical route.”
BIDMC is also the only New England institution participating in a national trial of active surveillance, known as the Prostate Cancer Active Surveillance Study (PASS). Chang and Dr. Andrew Wagner are enrolling patients in this study, which is designed to identify and validate biomarkers — proteins, DNA, RNA, hormones — that predict aggressive prostate cancer.
BIDMC already has the largest single-institution active surveillance PASS study cohort in New England with 150 patients currently enrolled.