Active Surveillance of Prostate Cancer

Introduction:

Prostate cancer is the second most common malignancy affecting men all over the world. It may present with quite variable symptoms pertaining to the lower urinary tract, like increased frequency of urination, particularly at night, poor urine flow, painful voiding, blood in the ejaculate, etc.

Advanced cases may present with bone pain, anaemia or renal impairment.

Many cases of prostate cancer are being diagnosed based on high PSA values done as a routine investigation in middle-aged or elderly patients or as screening tests in high-risk groups. The diagnosis is established by a prostate biopsy, which is performed on the suspicion of a high PSA or an abnormal digital rectal examination.

Not all cases of prostate cancer need urgent treatment. Approximately half of newly diagnosed cases may need deferred treatment or no treatment at all. Such patients are managed by providing them with an active surveillance management strategy. It aims to provide definitive treatment for men if localised disease progresses. Still, it reduces the risk of complications related to treatment in those patients in whom the disease does not progress.

Classification of Prostate Cancer for Treatment Purposes:

After diagnosis, before treatment, all prostate cancer patients are evaluated for staging. Based on the stage, grade and volume of the disease, the cancer is classified as localised, locally advanced or metastatic (spread beyond the prostate to other organs). If it is localised, the tumour is divided into favourable (low-risk), intermediate, or high-risk groups.

Treatment Options:

Deciding on a particular treatment option for localised cancer may be a complex process. There are many therapeutic options with more or less equivocal oncological results. The main treatment option is surgery in the form of radical prostatectomy or radiation therapy. Consideration is given to the probability of cure, life expectancy, any medical co-morbidities, adverse effects of treatment, and patient preference. It is usually shared decision-making between the physician and the patient based on current evidence. There is little disagreement that intermediate or high-risk prostate cancer patients do need some treatment. However, in low-risk (favourable) groups, treatment may be deferred.

What is active surveillance?

Nearly half of the patients at the time of diagnosis belong to the low-risk localised category. In these patients, there is very little likelihood of cancer progression during the patient’s life. Fewer than 10% of low-grade prostate cancers that are managed conservatively may have cancer-related deaths after 20 years of follow-up.

Such patients are regularly kept under watch, and if the disease shows any signs of advancement, active treatment in the form of surgery or radiation is offered. This process of following the patient with specific regular objective assessment tools for disease progression and employing definitive treatment if needed is called active surveillance.

Criteria for Active Surveillance

1- Low-volume disease

The disease is considered low-volume when

⇒ The cancer is diagnosed only based on a high PSA

⇒ Cancer is diagnosed on the histopathological examination of the prostate specimen when it is operated on for benign disease or

⇒ A small nodule is palpable in one half of the prostate.

2- Favourable Disease

Favourable (low) grade on the biopsy of the prostate and less than 33% of the cores are involved.

3- low levels of PSA.

It should be below the level of 10.

How is active surveillance performed?

⇒ Active surveillance is performed by monitoring PSA, doing a digital rectal examination and repeating a prostate biopsy.

⇒ PSA is done at three monthly intervals for the first two years and then six monthly. PSA doubling time is particularly noted.

⇒ A digital rectal examination is performed annually.

⇒ A prostate biopsy is repeated at two years and then at five years.

⇒ When active surveillance should be abandoned and active treatment given

⇒ If the disease advances on clinical examination PSA starts increasing, particularly if the doubling time is three months or less.

⇒ Biopsy grade increases on repeat biopsy of the prostate.

Risks Associated with Active Surveillance:

⇒ Patient’s anxiety over disease progression.

⇒ Risk of repeated prostatic biopsies.

⇒ Concerns regarding disease progression.

Proponents of Active Surveillance:

A growing body of evidence supports active surveillance for men with low-risk diseases (1, 2, 3). Delayed treatment does not appear to risk a significantly poorer outcome in those who elect active surveillance versus immediate treatment (4). Active surveillance was associated with tremendous quality-adjusted life expectancy compared to open prostatectomy radiotherapy and brachytherapy (5). No report has published evidence that has disproved the possibility of a cure after a period of active surveillance.

Benefits of Active Surveillance:

The disease may not progress cost-effectively.

It avoids complications related to any definitive procedure.

To Summarize, active surveillance emerges as a strategic and patient-focused method for managing low-risk prostate cancer cases. By employing regular assessments like PSA tests, digital rectal examinations, and periodic biopsies, healthcare professionals can promptly detect any signs of disease progression, allowing for timely intervention. This approach not only avoids unnecessary immediate treatments but also ensures a personalized and cost-effective prostate cancer care plan.

With robust evidence supporting its efficacy and the maintenance of quality-adjusted life expectancy, active surveillance offers a nuanced and practical solution within the intricate realm of prostate cancer management. Patients can navigate their diagnosis with confidence, knowing they are receiving tailored care that prioritizes their well-being, marking a significant stride in the evolution of prostate cancer treatment strategies.

Author:

Dr Irfan Ahmed

Consultant Urologist & Cancer Surgeon

References:

Cooperberg MR, Carroll PR, Klotz L. Active Surveillance for Prostate Cancer: Prognosis and Promise. J Clin Oncology 2011;29:3669-76.
Warlick C.Trock BJ.LandP, et al. Delayed versus immediate surgical intervention and prostate cancer outcome. J Natl Cancer Inst 2006; 98: 355-7.
Klotz L.Zhang L, Lam A, et al. Clinical results of long-term follow-up of a large active surveillance cohort with localised prostate cancer J Clin Oncol 2010;28: 126-31
Dall’era MA, Cowan JE, Simko Jet al. Surgical management after active surveillance for low-risk prostate cancer: pathological outcomes compared with men undergoing immediate treatment BJU Int 2011; 107: 1232-7
Hayes JH, Ollendorf DA, Pearson SD, et al. Active surveillance compared with initial treatment for men with low-risk cancer: a decision analysis. JAMA 2010; 304: 2373-80
Tosoian JJ, Trock BJ, Landis P, et al. Active surveillance program for prostate cancer: an update of John Hopkins experience. J Clin Oncol 2011; 29:2185-90