So, Dr. Scholz, there are two terms in prostate cancer when it comes to Gleason 6 that we
hear often. So, "active surveillance" and "watchful waiting." First of all, can you
define what those two are and if they're the same thing?
Technically, they're not. Though, they sort of mean the same thing. The idea is to forego
treatment in a something called "cancer" which sounds so counter-intuitive, but it's been
well-validated with scientific studies. Watchful waiting started 40 plus years ago when people
knew that prostate cancer was a low-grade process and so elderly men in their 70 plus,
80 plus years would have a digital rectal and they could feel a bump, and rather than
putting them through a dangerous surgery, they discovered that the cancer grew so slowly
that those men would go on and die of old age before they ever had a problem, or, if
they did have a problem, they would just do Lupron or castration and that would buy another
10 years, and very few if any would ever die of prostate cancer. That was watchful waiting.
Active Surveillance came about in younger men when the realization, yes, prostate cancer
is low-grade, but not every one of them will go so slowly that you die of old age, but
that if you watch those individuals extremely closely and the cancer started to misbehave,
you could then intervene with a treatment at that juncture and still cure them. So,
watchful waiting you're not trying to cure anybody. You're just sort of temporizing.
Active surveillance, you're trying to make sure that no one ever develops metastatic
disease.
So, what is the criteria to be an active surveillance patient?
It's usually Gleason 6, which is grade group 1 by Epstein's new criteria based on the biopsy,
of course, PSA less than 10 in general, though not always, and, you know, like an MRI or
something that doesn't show a scary ugly tumor in the front of the gland that has been missed
on biopsy. If people meet those criteria and when they have it well explained to them,
most people realize that that type of cancer doesn't spread, that it's safe to watch.
So, if a person goes and chooses active surveillance, but they're a little unsure of "Is it really
Gleason 3+3=6," what do they do? Is there a second process that they can do to check
that?
There certainly is. When you do the MRI one would want to know that there was concordance
between where the biopsy picked up the cancer, say at the base on the left side of the gland,
and an MRI that shows a shadow in that same area. If an MRI showed a shadow on the opposite
side that could raise a question of a cancer that got missed on the random biopsy and those
individuals should have further investigation to make sure it's really safe to do the active
surveillance. You may also be alluding to the fact that the pathologists that assign
a Gleason score are varying skills and sometimes in community hospitals they'll call something
a 7 a 6, or they'll call something a 6 a 7, and so it is prudent to have the biopsy slides
reviewed at a reference center to confirm that the Gleason score that has been assigned
is really accurate.
What is the long-term process that a patient needs to keep in mind when they're choosing
active surveillance? So, are they getting imaging, you know, once a year? Are they getting
their PSA tested every 3 months, every 6 months? Is there any diet that they should pay attention
to? This long term plan, because it seems to be like a lot of the patients that I meet
on active surveillance, are on it for quite some time.
Yes, thankfully, the people that are selected appropriately will stay on active surveillance
for years and perhaps for the rest of their lives. The monitoring process varies from
center to center. Throughout the United States, most men are advised to have random biopsy
ever 2-3 years and to get their PSA tested 2, 3, or 4 times a years. In our practice,
we've gotten away from random biopsies. We believe that the new high-quality MRIs are
more accurate than the biopsies and they're non-invasive, so we do an MRI once a years
and do PSAs a couple to three times a year, and that pretty much suffices. If the MRI
shows a new spot or an enlarging spot then we follow up with a targeted biopsy of that
to see if there's higher-grade Gleason that's developing. Men can get new cancers over time
and that's probably the number one reason that men go off active surveillance—not
that their grade 3+3 became a problem, but a—excuse me—that a higher grade cancer
appears over a period of years because prostate cancer is common and men can get more than
one.
Dr. Scholz, what are signs that you should stop active surveillance.
Usually, if an MRI is showing a new or an enlarging spot, and we do a targeted biopsy
and the Gleason score comes back higher than 6. That's a target or an indication that there
is—that it's time to do some treatment. The other thing to look out for is what's
called PSA density. Men run PSAs at varying levels, but they also have different size
prostate and so an normal PSA for active surveillance, they say, is less than 10, but we do have
some individuals who have very large prostate glands (normal being 40cc and some of these
people with big prostate could be as high as 150cc). So those men will run PSAs over
10 even though they have innocuous prostate cancer. So, the density is that ratio between
how big is your prostate to allow for how high your PSA is. But if men have a small
prostate and a high PSA that's called an abnormal PSA density, and you say, "where is this extra
PSA coming from if it's not a big gland. Is it prostate cancer?" sometimes it will be
prostatitis, but sometimes it could be prostate cancer that is being missed in some corner
of the gland and men that have high PSA densities need to be a little more careful and watch
more closely as to why their PSA is out of order in relation to the size of their gland.
So, do you have a particular diet that you suggest active surveillance patients do?
We used to because when we first started off with active surveillance, it was very avant-garde
and frightening and many people disagreed. Now, it has become mainstream and we realize
that the 3+3's don't spread. They don't behave like cancers. So, for me it's a little bit
disingenuous to try and scare people into whole big lifestyle change for something that
we think is innocuous. I could never argue against a good diet. It reduces incidence
of heart disease and other cancers and, yes, it may even reduce the incidence of new prostate
cancers, but that's a big step for something that we really perceive as being kind of a
small problem. The best diet for—as Dr. Moyad often says—is what's heart healthy
is prostate healthy, so you know, less fats, more vegetarian type situation, low-calorie,
don't be overweight, all these sorts of things people already know and they're all beneficial.
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