Active Surveillance for Prostate Cancer
Active surveillance is an increasingly popular option for men with low risk prostate cancer.
The concept was largely pioneered by Professor Laurence Klotz at the University of Toronto where A. Prof. Appu served as the first Australian Uro-oncology fellow. Following what is known as the Epstein criteria, Professor Klotz was able to identify a sub group of men with low risk prostate cancer who did not have any significant reduction in survival with observation alone.
Using a novel form of log linear PSA kinetics Professor Klotz and his team were able to predict for prostate cancer specific survival which was unaltered with close monitoring. The surveillance group can be divided into two further sub groups.
The more traditional group includes men over the age of 70 with low grade cancers or have other illnesses that may make traditional treatment options inappropriate. These men are generally followed with an indication to treat only in the advent of significant disease progression or symptomatic changes. The usual modality of treatment here is often limited to hormonal therapy or external radiation therapy in the majority.
The more topical or evolving group involves younger men who have chosen to avoid treatment to minimise the side effects of surgery or radiation therapy.
Men with Gleason pattern 6 disease involving a minimal amount of their prostate on biopsies can be safely followed with three monthly PSA’s and serial biopsies at 1 – 2 year intervals. In the event of disease progression these patients can be offered all treatment options including nerve radical prostatectomy or seed brachytherapy. The concept has evolved further with transperineal grid biopsies allowing more accurate sampling of the prostate and better prediction of prostate cancer progression risk.
This treatment option can be offered to men with higher volume pattern 6 disease or a small amount of Gleason 7 disease but this will need to be discussed carefully and evaluated carefully by the treating urologist.
Active surveillance may be the appropriate treatment for you if:
The cancer is detected early without any palpable anomalies on physical examination by your urologist.
The amount of cancer detected is small and limited to one area of your prostate.
Your Gleason score is low (pattern 3 +3=6 or lower) which indicates a slower growing less aggressive form of cancer.
You may have other health problems which could potentially affect your life expectancy or be made worse by treatment of the prostate cancer.
You may have a strong desire to minimise the morbidity of treatment which can include damage to your erections or potential control of your urine and will need to be monitored carefully. In younger patients this will often involve many years of close observation and need for repeat biopsies but precludes the need for surgery or radiation in the majority of patients with such low grade disease.
The greatest advantage of active surveillance is to totally eliminate any potential risk associated with treatment primarily affecting erections and control of the urine. The risks associated with active surveillance are:
Potential for cancer to grow and spread whilst on observation.
Anxiety provoking for a proportion of patients with the need for regular PSA testing and repeat biopsies.
The recognised limitations of PSA and digital rectal examination and even with biopsies, a small amount of high grade cancer can be missed.
As outlined previously the greatest benefit is the avoidance of any potential side effect with treatment, in particular erectile dysfunction.
There is mounting evidence that small volume Gleason pattern 6 prostate cancer has an excellent prognosis with almost similar survival curves without on recent trials (PIVOT). As such in patients who have been carefully assessed and monitored closely, the risk of progression is minimal.
What you can expect:
As part of the active surveillance you will be required to have regular visits and monitoring with your urologist. These will initially be performed on a three monthly basis but will later be stretched to six months. At these visits the urologist will often perform a digital rectal examination, PSA blood test and occasionally a transrectal ultrasound.
A prostate biopsy is usually performed with a transperineal grid at the time of commencement of active surveillance and then repeated between 12 – 18 months later. The biopsies are usually repeated on a 2 – 5 yearly basis and provides further reassurance that the tumour remains indolent.
Research data and results:
The safety and success of active surveillance continues to be demonstrated on many international studies. This has become the mainstay treatment for low risk, low volume Gleason 6 prostate cancer in many international centres. It can be offered in careful settings to patients with small amounts of Gleason 7 prostate cancer in expert hands.
The majority of patients selected out for active surveillance can expect stable or slow growth in their tumour with no significant risk to their life expectancy. There will be a small proportion of patients who harbour high grade disease and this should be picked up on serial examinations and repeat biopsies.
At this stage there is no clear cut evidence that patients who are subsequently treated after an initial period of surveillance have any significant reduction in their survival for low risk prostate cancer.