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Active Surveillance Prostate Cancer Guidelines

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When To Choose Active Surveillance

Active Surveillance for Prostate Cancer | Prostate Cancer Staging Guide

Your healthcare provider may recommend active surveillance if you have:

  • A small tumor thats only in your prostate
  • A slow-growing cancer
  • A low risk the cancer will grow or spread
  • A tumor that isnt life threatening

There are 4 parts to active surveillance monitoring. They are a prostate biopsy, prostate magnetic resonance imaging , prostate-specific antigen blood testing, and a digital rectal exam . You may also have genetic testing.

Your care team will use the results from all of these tests to see if active surveillance is the right treatment for you.

Active Surveillance Testing Schedule

Medical experts offer various recommendations regarding frequency of testing and when to start treatment during active surveillance. The American Society of Clinical Oncology recommends the following periodic evaluations while under active surveillance for prostate cancer:

  • PSA testing every three to six months

  • A digital rectal exam at least once a year

  • A prostate biopsy at least every two to five years

If test results or symptoms indicate the cancer is progressing, treatment is recommended with the intention of curing the disease.

Active Surveillance Guidelines For Prostate Cancer

J. Kellogg Parsons, MD, MHS

Hi. My name is Dr. Kellogg Parsons. I am at the Morris Cancer Center at the University of California, San Diego. I would like to talk to you today about active surveillance for prostate cancer. As many of you know, prostate cancer is the most common noncutaneous malignancy among American men. The lifetime risk of being diagnosed with prostate cancer is about 1 in 6.

Nowadays, as a result of screening with the prostate-specific antigen test and digital rectal examination, about 50% of newly diagnosed men present with localized, less aggressive disease. Some good research suggests that about 50% of these patients are treated unnecessarily aggressively with surgery or radiation.

The point of active surveillance is to monitor men with newly diagnosed prostate cancer and to determine when and if patients should ever be treated. I would like to talk now about 3 things: guidelines for enrollment into a prostate cancer active surveillance program guidelines for monitoring in an active surveillance program and guidelines for what should be considered disease progression in an active surveillance program.

I am Dr. Kellogg Parsons at the Morris Cancer Center at the University of California, San Diego. Thank you for listening.

Cite this: J. Kellogg Parsons. Active Surveillance Guidelines for Prostate Cancer – Medscape – Jun 22, 2011.

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Top Candidates For Active Surveillance

You may be a candidate for active surveillance if you meet the following qualifications:

  • Your cancer is confined to the prostate.

  • Your tumor is small and is expected to grow slowly.

  • You arent experiencing any symptoms.

  • You have the ability to live with cancer without worry reducing your quality of life.

  • You value near-term quality of life to a greater extent than any long-term consequences that could occur.

  • You have a relatively long life expectancy and may benefit from curative local therapy if your cancer progresses.

Men with localized prostate cancer that is intermediate risk or higher and with more than a limited life expectancy usually require local treatment. They are not good candidates for active surveillance.

When it comes to active surveillance, each patient should carefully weigh the potential loss of quality of life with treatment against the possibility that the window of opportunity for cure will disappear without treatment.

Who Should Receive Active Surveillance In Prostate Cancer

Active Surveillance for Prostate Cancer

Patients who harbor low-volume 3+3 tumors or 3+4 tumors with only a small percentage of grade 4 are eligible for active surveillance. The use of active surveillance in the United States has increased in recent years, with over 40% of low-risk tumors managed in this manner, and even higher rates for men over 75 years of age. Active surveillance is different from watchful waiting, which is usually reserved for elderly men with reduced life expectancy. In watchful waiting, the physician will not perform serial tests such as biopsies because there is no curative intent, so treatment is only given for symptomatic progression. In contrast, active surveillance infers that the patient is followed with a schedule of serial PSA tests and biopsies, with the latter meant to detect patients who convert from a low-grade to an intermediate- or high-grade tumor over time.

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Observation Or Active Surveillance Vs Treatment

A few large studies have compared observation and surgery for early-stage prostate cancer, but the evidence from these studies has been mixed. Some have found that men who have surgery might live longer, while others have not found a difference in survival.

So far, a few studies have compared active surveillance to treatments such as surgery or radiation therapy. Men who undergo surgery or radiation do not appear to live longer than those that undergo active surveillance, but their cancer might stay away longer and spread less.

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Bekelman JE, Rumble RB, Chen RC, Pisansky TM, Finelli A, Feifer A,et al. Clinically Localized Prostate Cancer: ASCO Clinical Practice Guideline Endorsement of an American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology Guideline. J Clin Oncol. 2018 32: 3251-3258.

Chen RC, Rumble RB, Loblaw DA, Finelli A, Ehdaie B, Cooperberg MR, et al. Active Surveillance for the Management of Localized Prostate Cancer : American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol. 2016 Jun 20 34:2182-90. doi: 10.1200/JCO.2015.65.7759. Epub 2016 Feb 16.

Last Revised: August 1, 2019

Criteria For Selecting Active Surveillance

No published randomised controlled trials were identified that compared immediate definitive treatment with active surveillance and met inclusion criteria. However, several relevant randomised controlled trials are currently underway . The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.

Three cohort studies at high risk of bias reported mortality and quality-of-life outcomes in men who underwent either surveillance or immediate treatment. These studies demonstrated similar prostate cancer-specific survival rates for men with prostate cancer managed by active surveillance. In all but one study, men were aged greater than 50 years.

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Observation Or Active Surveillance For Prostate Cancer

Because prostate cancer often grows very slowly, some men who have it might never need treatment. Instead, their doctors may recommend observation or active surveillance.

The terms active surveillance and observation mean something slightly different:

  • Active surveillance is often used to mean monitoring the cancer closely. Usually this includes a doctor visit with a prostate-specific antigen blood test about every 6 months and a digital rectal exam at least once a year. Prostate biopsies and imaging tests may be done every 1 to 3 years as well. If your test results change, your doctor would then talk to you about treatment options to try and cure the cancer.
  • Observation is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a mans symptoms to decide if treatment is needed. This treatment is most often meant to control symptoms from the cancer, but not to cure it.

No matter which term your doctor uses, its very important for you to understand exactly what they mean when they refer to it.

What Are The Advantages And Disadvantages

What is Active Surveillance for Prostate Cancer?

Advantages

  • As you wont have treatment while youre on active surveillance, youll avoid the side effects of treatment.
  • Active surveillance wont affect your everyday life as much as treatment might.
  • If tests show that your cancer might be growing, there are treatments available that aim to cure your cancer.

Disadvantages

  • You might need to have more prostate biopsies which can cause side effects, and which some men find uncomfortable or painful.
  • Your cancer might grow more quickly than expected and become harder to treat but this is very uncommon.
  • Your general health could change, which might make some treatments unsuitable for you if you did need them.
  • Some men may worry about not having treatment, and about their cancer growing but you can change your mind and have treatment instead if this is a problem.

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Questions To Ask Your Doctor Or Nurse

You may find it helpful to take a list of any questions you have to your next appointment.

  • Am I going on active surveillance or watchful waiting?
  • How often will I have my PSA level checked?
  • Who will be in charge of booking my PSA tests?
  • Who will check my PSA level and give me the results?
  • How often will I see my doctor or nurse?
  • Will I have other regular tests or scans? If so, which ones and how often?
  • What test results would lead you to recommend treatment? Are there any specific results that mean I should have further tests?
  • What treatments could I have if my cancer grows?
  • What can I do to improve my general health?

Active Surveillance For Prostate Cancer

If diagnosed with localized prostate cancer , disease management can take many forms, depending on the risk category of disease. Patients with low-grade, slow-growing tumors confined to the prostate gland may consider active surveillance. This involves monitoring prostate cancer in its localized stage until your doctor feels that further treatment is needed to halt the disease at a curable stage.

According to the American Society of Clinical Oncology, patients with low-risk, low-grade disease can consider active surveillance. It may also be an option for patients with a Gleason score of 7. Patients within these categories may choose to postpone prostate cancer treatment because of its associated risks and side effects.

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When Are These Options Used

One of these approaches might be recommended if your cancer:

  • Isnt causing any symptoms
  • Is expected to grow slowly
  • Is just in the prostate
  • Is associated with low PSA level

They are not likely to be good options if you have a fast-growing cancer or if the cancer is likely to have spread outside the prostate . Men who are young and healthy are less likely to be offered observation, out of concern that the cancer might become a problem over the next 20 or 30 years.

Observation and active surveillance are reasonable options for some men with slow-growing cancers because it is not known if treating the cancer with surgery or radiation will actually help them live longer. In active surveillance, only men whose cancer is growing are treated. For some men. these treatments have risks and side effects that may outweigh their benefits. Other men are not comfortable with observation or active surveillance because the cancer might grow and spread, limiting treatment options and the possibility of treating the cancer successfully. Some men accept the possible side effects of treatments to try to remove or destroy the cancer.

Other Biomarkers For Active Surveillance

Article of the Month: Indications for Intervention During Active ...

A variety of other commercially available serum, urine, and tissue biomarkers have been introduced to help clinicians decide whether to initiate and maintain a patient on active surveillance. Their value relative to MRI has not been tested adequately to draw conclusions as to whether these can be used in place of MRI or as an adjunct to MRI.

One of these serum markers is the Prostate Health Index, which combines total, free, and proPSA using a mathematical formula. This test was previously shown to predict changes on biopsy in men on active surveillance, and in the future might be used to monitor patients in conjunction with mpMRI. Several genomic tissue tests including Prolaris, Oncotype DX, and Decipher are also commercially available to help determine aggressiveness beyond the information provided by Gleason score. These may be used to help assess eligibility for active surveillance in borderline cases such as high-volume Gleason 6 or low-volume Gleason 3+4 however, there are no published data on their utility for monitoring during surveillance, and they require tissue from a biopsy.

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Exceptions And Barriers To Active Surveillance

In his UCSF program, Dr. Cooperberg said, about 95% of men diagnosed with low-risk prostate cancer are put on active surveillance. As an academic center that began implementing and studying active surveillance in the mid-1990s, thats likely higher than what is typically seen in the United States, he acknowledged.

But a reasonable target for the time being is around 80%, he said. Thats consistent with where rates top out in countries like Sweden and in other large, integrated health care systems in Europe where active surveillance has long been standard practice.

The bottom line, Dr. Cooperberg said, is that even though the vast majority of men with low-risk prostate cancer should be put on active surveillance, there will always be exceptions.

Those exceptions, for example, can include men with a strong family history of prostate cancer or who have urological symptoms related to the disease that immediate treatment can help to alleviate.

There can also be considerations that go beyond clinical or biological factors. For patients in rural areas or those who lack reliable transportation, anything that requires regular visits to the hospital or doctors office over a long period could push some men toward choosing immediate treatment, Dr. Watts said.

In addition, she noted, it can be challenging to explain the medical basis for active surveillance. In some patients minds, opting for active surveillance means missing a window of opportunity for cure, she said.

More Active Surveillance But Not Enough

To conduct their study, Dr. Cooperberg and his colleagues looked at data from all men newly diagnosed with prostate cancer in the AUA Quality Registry. This registry collects real-time data from more than 240 participating US urology practices and more than 2,100 urologists.

Overall, of the more than 84,000 patients covered by the study, 20.3% were diagnosed with low-risk disease. The number of men diagnosed with low-risk disease actually fell during the study period, from about 24.6% in 2014 to 14.0% in 2019. That finding is consistent with other recent studies showing a decline in low-risk diagnoses, which researchers have attributed to fewer men being screened via PSA testing.

But even as diagnoses of low-risk disease have dropped, more men with low-risk disease are opting for active surveillance, Dr. Cooperberg reported. In 2014, 26.5% of men with low-risk prostate cancer chose active surveillance. By the end of 2021, 59.6% did.

Rates of active surveillance also increased among men diagnosed with intermediate-risk prostate cancer, which is considered to have a modestly greater likelihood than low-risk prostate cancer of progressing to the point where it could be fatal.

The variability in the use of active surveillance is alarming, Dr. Parnes said. It likely reflects, at least to some degree, entrenched patterns of care among some urologists. For some, I suspect their feeling is, I treat cancer, and this is cancer. Im not having this conversation , he said.

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Active Surveillance Over Prostate Cancer Treatment: Is It Right For You

More men are choosing active surveillance for their low-risk prostate cancer diagnosis. While this “wait and see” approach may appear passive, it can provide opportunities for men to get more active about their overall wellness.

There is a good chance men will live a long time with low-risk prostate cancer, and they should do everything they can to ensure their life is the healthiest and the highest quality it can be.

The choice to follow active surveillance begins after a prostate biopsy, which provides information needed to predict how fast the cancer is growing and the probability of spreading.

Generally, active surveillance is an option for men with low-grade cancer that hasnt spread, who have a PSA level of less than 10 nanograms per milliliter and a Gleason score of 6 or less.

The reason for choosing active surveillance is to defer=”defer” immediate surgery or radiation, since low-grade prostate cancer is unlikely to progress. That also means avoiding possible side effects of treatment, such as erectile dysfunction, urinary incontinence, and bowel problems.

Men on active surveillance regularly follow up with their doctor for PSA tests, MRI scans, and prostate biopsies. If there is evidence the cancer has progressed, such as a higher Gleason score or cancer in a greater number of biopsies, then treatment should be considered.

Image: Westend61/Getty Images

How Is Active Surveillance Done

Active Surveillance in Favorable Intermediate-Risk Prostate Cancer

Although the protocol can vary, recommendations for active surveillance generally call for routine PSA tests and prostate biopsies to check for any indication that the cancer might be growing.

For example, patients at Montefiore Health System in New York City get a PSA test every 36 months, at least initially, and an MRI-guided biopsy a year after diagnosis, said Kara Watts, M.D., a urologist at the hospital who specializes in treating prostate cancer but was not involved in the study.

After the initial PSA tests and biopsy, how often they are performed depends largely on the patients particular situation, Dr. Watts explained.

We have a flexible protocol, particularly for people at both ends of the spectrum, she continued. For a man in his 70s and a life expectancy of 510 years , she said, additional PSA tests or biopsies may only be conducted every few years or only if he has symptoms. An otherwise healthy man in his 50s, on the other hand, will usually continue to have PSA tests and MRI-guided biopsies on a schedule similar to the initial protocol.

At the NIH Clinical Center, where Dr. Parnes sees patients, in addition to routine PSA testing, MRI-guided biopsies are used to help inform decisions around whether to pursue active surveillance and as part of the surveillance protocol.

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