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Prostate Cancer 3+4 Active Surveillance

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Who Should Choose Active Surveillance

Active Surveillance 101 | Ask a Prostate Expert, Mark Scholz, MD

Some of the characteristics that might qualify you for Active Surveillance include grade group 1 or Gleason 6, a PSA level < 10, cancer that is confined to the prostate, and/or cancer that is very low volume when biopsied.

The ideal candidate for Active Surveillance has low-risk prostate cancer. Learn more about Risk Groups.

Who Has Active Surveillance

You might have active surveillance if:

  • your cancer is contained in the prostate gland. This is localised prostate cancer
  • you have a Cambridge Prognostic Group of 1, 2 or 3. This is similar to a low or medium risk localised prostate cancer
  • you can have treatment that aims to cure if the cancer starts to grow

Your doctor will discuss the possible benefits and risks of active surveillance. They make sure that you’re happy with whichever decision is made.

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

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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.

Active Surveillance For Prostate Cancer Is Generally Safe Study Results Show

Prostate Cancer Markers

Badar M. Mian, MDUrology Times Journal

“This large cohort study confirms the safety of AS, as shown in the low rate of metastasis or death, including those who subsequently converted to treatment,” writes Badar M. Mian, MD.

Active surveillance for the management of low-risk prostate cancer is slowly becoming the de facto standard of care. Although the adoption of AS has been increasing, still too many patients with low-risk prostate cancer appear to be undergoing active treatment. A frequently voiced concern by patients and physicians alike is the risk of disease progression and the need for active treatment. These issues were addressed in the recent study by Cooley et al of a large, multicenter cohort of men converting from AS to active treatment.

The investigators evaluated the clinical and pathologic parameters associated with the time to conversion from AS to treatment in the pooled cohort of 7279 patients from 28 institutions between 1991 and 2018. They also evaluated the association of germline genetic variants to conversion to treatment in a subset of patients. The primary question to be addressed was the time from prostate cancer diagnosis to conversion to treatment. Those men followed without a strict AS protocol were analyzed in the same manner as those on AS.


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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?

Point: Should Active Surveillance Be Used For Gleason 3+4 Prostate Cancer

Sanoj Punnen, MD, MASOncology

In this Point/Counterpoint, Drs. Bhat and Punnen argue that active surveillance can be beneficial for patients with intermediate-risk prostate cancer.

While the use of active surveillance among men with low-risk prostate cancer has increased, its role in men with intermediate-risk disease remains debatable. Current American Society of Clinical Oncology /Cancer Care Ontario guidelines recommend treatment for most men with intermediate-risk disease, but state that men with low-volume Gleason 3+4 prostate cancer may be considered for active surveillance. The recent National Comprehensive Cancer Network guidelines list active surveillance as an initial therapy option for men with favorable intermediate-risk disease, which they define as clinical stage T2b-T2c, Gleason score 3+4, or prostate-specific antigen levels at 1020 ng/mL, as well as less than 50% of positive biopsy cores. While it remains an option in current guidelines and has been increasing in contemporary clinical practice, there remains significant controversy over the safety of active surveillance in intermediate-risk prostate cancer.

Financial Disclosure:The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

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Low Volume Gleason 3 + 4 = 7 Disease: Is Active Surveillance A Realistic Option

It would be easy to misinterpret a recent paper from the group at Johns Hopkins about the pathological outcomes of men initially diagnosed with very low-, low-, or favorable intermediate-risk localized disease and treated by immediate radical prostatectomy.

This new paper by Patel et al. is entitled Adverse pathologic findings for men electing immediate radical prostatectomy: defining a favorable intermediate-risk group and has recently been published in JAMA Oncology.

The question that the authors set out to address is this one:

Is there a subset of men with Gleason 3 + 4 = 7 intermediate-risk prostate cancer with favorable characteristics to minimize risk of adverse pathologic findings at surgery?

To try to answer this question, Patel et al. carried out a retrospective analysis of data from 6,721 men, all of whom had initially been diagnosed with clinically localized very low-risk , low-risk , and low-volume intermediate-risk prostate cancer between January 2005 and July 2016, and who had elected to be treated by radical prostatectomy by one of 15 different surgeons at Johns Hopkins during that time frame.

During the same time frame, Johns Hopkins was following 2,052 men with VLR and LR prostate cancer on active surveillance but their active surveillance cohort excludedany men with LVIR prostate cancer.

The authors found that, of the 6,721 men who elected to have radical prostatectomy at Johns Hopkins:

What Happens During Active Surveillance

PI-RADS, Active Surveillance Protocols for 3+3=6 & 3+4=7, & Genomic/Genetics Tests | Mark Scholz, MD

Active surveillance is a form of treatment. Its not the same as receiving no treatment at all. With this method, we put off treatments, such as surgery and radiation therapy, because tests indicate that the tumor is currently not life threatening or is at a low risk of spreading or getting worse.

Your doctors team up to monitor your tumor for any signs that it may be changing and reevaluate your treatment if the cancer becomes more active. For example, if your Gleason score or prostate-specific antigen level start to rise, we may recommend stopping active surveillance and starting another type of treatment.

The key to making sure that active surveillance is the appropriate treatment approach for you is determining as certainly as possible that the disease is confined to the prostate and does not have aggressive features. To do this, we may want you to have additional testing.

Prostate MRI provides the best look at the entire prostate and can identify areas of concern within the gland that might not have been sampled during the initial biopsy procedure. For some men, we may recommend a second prostate biopsy to better determine risk. We may also do genetic studies of your biopsy material to determine whether active surveillance is an appropriate management strategy. By combining several tests, we can assess the risk that your tumor will grow.

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Active Surveillance And Focal Therapy For Low

Laurence Klotz

Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Canada

Correspondence to:

Keywords: Active surveillance focal therapy low risk prostate cancer minimally invasive conservative management biomarkers

Submitted Jun 01, 2015. Accepted for publication Jun 05, 2015.

doi: 10.3978/j.issn.2223-4683.2015.06.03

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.

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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.

The Risks Of Active Surveillance For Prostate Cancer

Point: Should Active Surveillance Be Used for Gleason 3+4 Prostate Cancer?

Anxiety is a common problem among cancer patients. That constant uncertainty can take a toll on peoples emotional well-being, especially when the monitoring lasts a very long time. Then, there are the regular medical appointments.

Those affected will without a doubt spend a long time in the hospital, consulting their doctors and analyzing cancer progression.

During the monitoring period, cancer can spread. If it does, the patients might have missed their chance of efficient treatment.

When that happens, those with cancer are given fewer treatment possibilities.

The treatment necessary can require more drastic treatment measures compared to more minor cancer treatments.

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Counterpoint: Should Active Surveillance Be Used For Gleason 3+4 Prostate Cancer

Michael R. Abern, MDOncology

In this Point/Counterpoint, Drs. Madueke and Abern argue that active surveillance should not currently be considered for patients with intermediate-risk prostate cancer.

Active surveillance has been proven safe in men with low-risk prostate cancer. More recently, it has been suggested that the inclusion criteria for active surveillance should be expanded to include men with Gleason score 3+4 histology. The National Comprehensive Cancer Network guidelines list active surveillance as an option for favorable intermediate-risk prostate cancer, which is defined as confined to the organ, with a clinical stage of T2, Gleason score 3+4, or a prostate-specific antigen level of 1020 ng/mL, as well as less than 50% of positive biopsy cores. Much of the rationale for this guideline is based on the revised International Society of Urological Pathology definition of Gleason pattern 4 disease from 2005, which has resulted in reclassification of cases formerly reported as Gleason score 3+3 to 3+4 and 4+3. However, we propose that active surveillance should not be routinely offered to all men with Gleason score 3+4 prostate cancer, since the drawbacks of active surveillance are potentially magnified in this population.

Financial Disclosure:The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

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 small
  • 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.

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What Happens During Watchful Waiting

You have blood tests to measure your PSA levels. You usually have this at least once a year. Your GP can arrange for you to see a prostate cancer specialist if you have:

  • a sudden rise in your PSA level
  • develop any new symptoms, such as bone pain

Your prostate cancer specialist might recommend hormone treatment. The treatment aims to shrink and control your cancer rather than cure it.

What Does Active Surveillance Mean

Active Surveillance for Prostate Cancer | Prostate Cancer Staging Guide

A patient with localized prostate cancer can opt for active surveillance. But, cancer must be slow-raising, confined, and low-grade.

Active surveillance is a monitoring routine where a physician will closely assess the disease until additional or definitive treatment becomes necessary to halt cancer at a curable stage.

Active surveillance is only suitable for low-volume tumors with a 3+3 Gleason score or a 3+4 Gleason score tumor with a tiny percentage of grade 4 of a prostate cancer grade.

Gleason 3+3 is the lowest grade cancer in the typical Gleason scoring system, while doctors consider Gleason 6 a malignancy.

In other words, the best candidates are those with confined prostate cancer or a small tumor that might grow relatively slowly.

That means a patient has developed low-risk prostate cancer. This prostate cancer is unlikely to impair them during their lifetime.

However, active surveillance has nothing to do with watchful waiting. Watchful waiting is typically suitable for older patients with a decreased life expectancy.

During watchful waiting, the urology expert will not do a series of tests, like a biopsy, since there isnt a curative goal.

Therefore, the treatment that patients do receive is tailored towards symptomatic progression.

Compared to active surveillance, prostate cancer patients procure a schedule of tests, like a biopsy and a PSA test .

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Drugs Or Active Surveillance For Low

In the past, even low-risk prostate cancer patients were often treated with surgery or radiation therapy, as men took an aggressive approach to getting rid of cancer despite the potentially serious side effects of treatment.

But in recent years there has been a marked shift away from immediate treatment. Approximately 60% of patients with low-risk prostate cancer currently refuse treatment, opting for active surveillance instead.

The American Urological Association is pushing for this proportion to rise even further, to at least 80% in the near future, as new research highlights the slow growth and even noncancerous nature of most low-risk prostate tumors.

However, some researchers, supported by pharmaceutical companies, seem to be exploring a new approach to treating these patients.

Instead of advocating only AS for this group, they are considering the use of oral androgen receptor inhibitors , a class of potent and expensive hormonal drugs that include apalutamide, enzalutamide, and darolutamide. So far, these drugs have only been approved for use in the treatment of advanced prostate cancer. Wholesale prices for these drugs exceed $150,000 per year and can reach six figures.

The prospect of using drugs for patients with less aggressive tumors has alarmed some cancer specialists.

The trial began in 2016, before AS had blossomed as a treatment approach for the disease in the United States.

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