Prostate cancer—a disease in which cancer forms in the prostate, a gland located just below the bladder and in front of the rectum in males—is often slow-growing, and is most frequently diagnosed in older men. Since many prostate cancers proliferate slowly, an approach called “active surveillance” is frequently used to minimize the risk of side effects associated with curative treatments, such as surgery or radiation.
Ideal candidates for active surveillance are men with low-risk prostate cancer, or men who would not derive long-term benefit from aggressive treatment due to their overall health. Active surveillance entails close monitoring of a biopsy-proven prostate cancer, proceeding next with definitive local treatment if and when the disease appears more aggressive than initially anticipated.
Patient selection for active surveillance is critical. Active surveillance is proven as a preferred approach for men whose prostate cancer presentation suggests very little risk of progression beyond the prostate gland over the next 10 to 15 years. Criteria used to determine the feasibility of active surveillance include Gleason grade (a measure of the aggressiveness of the cancer cells under the microscope), volume of disease (determined by the amount of disease observed in a standard 12-core biopsy specimen), and prostate-specific antigen (PSA) level. Good candidates for active surveillance have low-grade prostate cancer with a PSA of less than 10 nanograms per milliliter and fewer than one-third of biopsy cores that test positive for disease.
The goal of active surveillance is to completely avoid or substantially forestall curative treatment with surgery or radiation, or standard therapies sometimes associated with long-term complications, such as urinary, bowel, and erectile dysfunction.
Monitoring includes PSA testing three to four times per year, prostate exams, and repeat prostate biopsies. Prostate MRIs are also being studied as valuable additions to the monitoring program. These regular examinations allow doctors to monitor the cancer and determine if/when the cancer shows signs of progression, in which case further treatment may be needed. Evidence of tumor growth or discovery of an intermediate- or high-grade Gleason score upon re-biopsy signals that definitive treatment is needed.
Long-term studies of men with low-risk prostate cancer have demonstrated that active surveillance is safe and that a majority of patients can successfully forego surgery or radiation for over 10 years.
Deciding whether to follow an active surveillance protocol in lieu of active treatment is a decision that will vary depending on the patient’s age, disease prognosis, and personal preferences.