Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
Today we're going to cover the topic of active surveillance for men with prostate cancer.
Active surveillance is a process of ongoing monitoring for men who harbor very low-grade
cancers in the prostate. An essential ingredient of active surveillance is accurate staging.
Men need to be confident that the type of cancer they have is indeed the low-grade form
that won't spread. To ensure this is the case staging with biopsies, imaging, and blood
tests is essential to make sure there's no higher grade disease lurking in a corner of
the prostate that's been missed.
Postponing treatment of something called cancer is certainly counterintuitive. Why are so
many men deciding to do active surveillance? Well first, bottom line, the treatment is
clearly worse than the disease. Men can experience immediate incontinence, erectile dysfunction,
and other complications with treatment. This can all be avoided if they postpone treatment.
This certainly is one of the attractive aspects and one of the reasons why men are doing active
surveillance. Another attractive aspect of active surveillance is our realization that
overall medical technology is moving forward very, very quickly. Every year that people
postpone treatment, they grandfather into newer and better treatment. Another attractive
thing about why men are doing active surveillance is that the technology for monitoring gets
better every year too. It gets safer and safer to do active surveillance since we have better
imaging, better genetic technology, and just a plain better understanding of what prostate
cancer is and how it behaves.
What exactly is the monitoring process? Unfortunately, for many years we didn't have adequate imaging
that was accurate enough to rely on 100%. To be safe, therefore, men had to have repeated
biopsies every one to three years depending on different factors. Fortunately, imaging
technology has advanced tremendously in the last two to four years and we now have several
studies proving that 3T multiparametric MRI is more accurate than a biopsy. It's also
non-invasive. This is really good news for men considering that the complications of
random biopsy can include: Sepsis, erectile dysfunction, pain, and bleeding. Many men
are now adopting an approach of MRIs annually rather than doing periodic biopsies. If MRIs
are stable over time, and the assumption is that these MRIs are done at a center of excellence,
there's no need for routine biopsies.
Another basic component of active surveillance is, of course, doing PSA testing every 3-6
months. Men have to be careful because we know that PSAs can bounce around quite a bit
and a simple rising PSA may not signal an advance in the cancer. But PSAs are done sort
of like a backstop—a way to crosscheck and make sure something's not being missed, and
the typical PSA has to be interpreted in light of how large the prostate is. Men with big
prostates are going to run higher PSAs, men with small prostates are going to run lower
PSAs.
So the monitoring process for active surveillance, therefore, would consist of a PSA every 3-6
months. Men that have been doing this for several years can usually graduate to every
six months. Initially, when we're not quite certain we'll start off with every three months.
And then ongoing imaging with MRI every year and after a number of years some men may be
able to graduate to every other year.
Who exactly is eligible for active surveillance? The standard has been evolving over the last
ten years. When active surveillance first came on the scene all men had very small amounts
of grade six. Those people did so well that the doctors started to expand the cohort to
include just about any amount of grade six. Now more recently, studies suggesting that
men that have small amounts of a subtype of grade seven (that's 3+4, not 4+3) are also
eligible for active surveillance. The belief presently is that the percentage of grade
four in the biopsy should be under 10-20%. Apart from the biopsy results, the typical
PSA threshold—it's upper limit is around ten; however, some men have incredibly large
prostates and they may be running a PSA of ten simply from BPH. We shouldn't exclude
those people simply on the basis of a raw, one-size-fits-all, cutoff.
So overall, present thinking is that just about anyone with grade 3+3=6 and select patients
with 3+4 are eligible to do active surveillance.
Why is active surveillance still controversial? It's estimated that half of the men diagnosed
every year with grade six still proceed on have immediate radical therapy. I think it's
quite understandable given that this low-grade harmless process is still called cancer. That
word is so powerful and emotionally charged many people cannot get past the fact that
this type of "cancer," and we put cancer in quotes, is really harmless. The other problem,
of course, is that the surgeons and radiation therapists that are monitoring and supervising
these men are really trained in treating prostate cancer. They're also a little nervous because
even if one case sneaks by and someone gets a cancer that spreads they're going to feel
terribly responsible and also have a concern about getting a medical malpractice suit on
their hands. So many of the physicians are rather half-hearted about the active surveillance
process. If you decide to do active surveillance, you need to be aware that your physician may
not be totally bought into the idea. That does not mean that active surveillance is
unsafe. The underlying science is extremely strong. It just means that this is a new type
of technology and that the system is still getting used to the idea.
Today we've given you a very brief introduction to the field of active surveillance. If you
want to learn more go to our website at PCRI.org and subscribe to our channel