Active Surveillance for Prostate Cancer
Early-Stage Prostate Cancer Patients "Watch and Wait"
More men diagnosed with early stage prostate cancer are choosing to defer treatment, preferring to monitor the status of their cancer by having regular exams and tests that are designed to let them know if they need to be treated or if they can continue to hold off.
The strategy used to be called “watchful waiting” but is now more often referred to as “active surveillance” when it refers to younger men.
In years past, physicians often encouraged men in their 70s and 80s to adopt the watchful waiting strategy. This was because prostate cancer usually grows slowly, and there was a good change that they would die from other causes.
But there has been a sea change in the thinking about the need for prostate cancer treatment. Today at BIDMC, more than 50 percent of younger men are adopting the active surveillance strategy. Ten years ago, only five to 10 percent of younger patients with low-grade, early stage prostate cancer were choosing to watch and wait.
A number of landmark studies in that time have shown the strategy is safe.
BIDMC Urologists Open-Minded
The urologists at BIDMC are in tune with the thinking that active surveillance is a safe strategy for appropriate patients. There are still urologists at other institutions who don’t share this confidence. Many still tell their patients they need immediate treatment.
Of course, many younger men with low-grade prostate cancer opt for treatment, whether it is surgery or one of a number of types of radiation therapy. Some men are uncomfortable living with cancer inside of them.
But the numbers who choose active surveillance are growing. Often this is because they fear the side effects of treatment — incontinence or erectile dysfunction or both.
Active surveillance usually involves getting blood tests that measure the levels of prostate-specific antigen or PSA, a protein linked to prostate cancer, as well as a digital rectal exam (DRE), every six months. In addition, a tissue biopsy every year or two monitors how much cancer is in the gland and how aggressive it might be. If changes occur, patients may decide to opt for treatment.
When watchful waiting is combined with regular blood tests and biopsies, the term “active surveillance” applies. In addition to the monitoring, many patients choose to adopt healthier diets, take supplements and increase regular exercise.
The Prostate Cancer Active Surveillance Study (PASS), the nation's largest clinical trial of active surveillance, is designed to identify and validate biomarkers — proteins, DNA, RNA and hormones — that predict aggressive prostate cancer. BIDMC is the only academic medical center in the Northeast participating in this study, under the leadership of Principal Investigator Andrew Wagner, MD, and co-Investigator Peter Chang, MD, both surgeons in BIDMC's Prostate Cancer Program.
Guidelines for Good Candidates
Active surveillance is not foolproof because the tests are not definitive. PSA tests are notoriously unreliable. That is why the search for new tests continues. In addition, a cancer that is growing or turning more aggressive may not be detectable by biopsy.
Generally, patients who are good candidates for active surveillance are those with what physicians term “T1c” cancer. This means:
- The tumor cannot be felt on a digital rectal exam
- The PSA level is under 10 ng/mL
- Cancer has been found on just one or two biopsy samples and none of the samples has more than 50 percent cancer
- The cancer grade on the Gleason score (a measure of the cancer’s aggressiveness) is not higher than 6 out of a scale of 10
A landmark 2012 study published in the New England Journal of Medicine looked at 731 men over 15 years. All had early-stage prostate cancer and were divided into two groups: one had surgery and the other did active surveillance. During the study, the largest of its kind, about 7 percent of the men died of prostate cancer. There was no difference in the prostate cancer mortality rate or the overall death rate between the two groups. Most men survived the disease whether they had treatment or not.
The study suggested what many doctors have long believed: While most prostate cancers are not life-threatening, the vast majority of men who are diagnosed with it receive aggressive treatments they don’t need. About 100,000 radical prostatectomies — surgeries to remove the prostate — are done in the U.S. each year.
Active surveillance is gaining traction among patients who realize their low-grade tumor does not necessarily need to be treated.