Active Surveillance for Prostate Cancer
This year more than 180,000 American men will be diagnosed with Prostate Cancer. But not all prostate cancers are alike. Some are small, slow-growing and pose little risk, while others grow quickly and need immediate treatment. If you have been diagnosed with a very early stage of prostate cancer, your doctor may recommend "active surveillance." Today, almost half of men with early-stage prostate cancer choose active surveillance as their course of treatment. Knowing more about active surveillance will help you work with your doctor to decide whether it is the right approach for you.
Prostate Cancer Basics
The prostate is a walnut-shaped gland that is part of the male reproductive system. It surrounds the urethra, the tube that carries urine and semen out of the body. The prostate makes fluid for semen to help protect and energize the sperm.
Prostate cancer starts when cells in the prostate gland begin to grow uncontrollably. Risk factors for prostate cancer include age, family history and race. One in seven men will be diagnosed with prostate cancer. Your chance of being diagnosed increases to:
1 in 5 if you are African-American; and
1 in 3 if you have a family history of the disease.
Early stages of prostate cancer usually don't cause symptoms. Men who do have symptoms, such as trouble urinating, may have a non-cancerous growth of the prostate called benign prostatic hyperplasia (BPH) or another common condition called prostatitis, which is an inflammation of the prostate. It's important to go to your doctor for regular check-ups about your prostate health and to talk to them about any changes in your urinary or sexual function.
There are two common tests to check the health of the prostate: the digital rectal exam and a blood test, called Prostate-Specific Antigen (PSA). PSA is a protein made by the prostate gland. A high level of PSA can be a sign of prostate cancer, but it can also be a sign of other prostate conditions, like BPH or prostatitis.
If prostate cancer is detected early-before it has spread outside of the prostate gland-it is more likely to be treatable. However, certain prostate cancer treatments can cause side effects. These side effects may include incontinence or erection problems. That is why in some cases, doctors recommend starting with active surveillance instead of other treatments, such as surgery and radiation.
How Does Active Surveillance Work?
Active surveillance is a type of close follow-up. It usually involves regular PSA tests and digital rectal exams to determine if the cancer is growing. It may also include prostate biopsies (tissue samples), which initially confirmed your prostate cancer and can now help predict how quickly the cancer is likely to grow and spread. If these tests show your cancer is growing, your doctor may discuss other forms of treatment with you.
As part of a standard biopsy, the doctor collects tissue samples by poking a thin needle, guided by ultrasound, into different areas of the prostate. With this procedure, 12 samples of prostate gland tissue are collected - 6 samples from the right side and 6 samples from the left side. However, these random biopsies can sometimes miss the cancer and its growth, which is why newer tests are helping doctors to be more precise in their findings, as well as their prediction about whether a man's prostate cancer is growing," Dr. O'Reilly says.
A biopsy test called fusion-guided biopsy is one of those newer tests. It fuses detailed MRI scans with live, real-time ultrasound images of the prostate. It begins with the patient undergoing an MRI. If the radiologist finds suspicious areas on the scan, the doctor will then use a software program to guide the biopsy needle precisely to where the suspicious area was seen. Genomic tests are another promising development for prostate cancer assessment. These tests look at the DNA of the cancer, to help doctors better predict its growth.
There is no universal agreement about how often tests should be done for men under active surveillance, says Keith J. O'Reilly, MD, FACS, a urologist with Chesapeake Urology in Westminster, Maryland. "If we decide a patient is very low risk, we'll check his PSA every six months. And 12 to 18 months after diagnosis, we'll usually do another biopsy. What we find will determine how often we test. Because there's no approved standard, we tailor it to our patients," he says.
Who Is a Candidate for Active Surveillance?
Men diagnosed with prostate cancer may be candidates for active surveillance if they:
are diagnosed with an early stage of prostate cancer that has not spread beyond the prostate
are not experiencing symptoms
have prostate cancer that is slow-growing
are older or have other serious health conditions which may interfere with prostate cancer treatment.
What Are the Pros and Cons?
The benefit of active surveillance is that it's a low-cost, safe option, with no side effects, that enables you to maintain your day-to-day quality of life. "Most men are relieved when I tell them they don't need treatment right away," Dr. O'Reilly says.
The risk of active surveillance is that the cancer can grow and spread to other parts of the body between doctor visits. This could make the cancer more difficult to treat.
Some men decide they do not want to live with even a small risk that the tumor could become more aggressive. They would prefer to accept the risk of side effects from other forms of treatment in order to remove or destroy the cancer.
"I tell my patients that cancers are like dog breeds - there are Chihuahuas and there are pit bulls," Dr. O'Reilly says. "If we find that we're dealing with a Chihuahua, then I recommend active surveillance."
Living with Active Surveillance: A Patient's Story
When Carl Snook, a now retired middle school principal, was diagnosed with early-stage prostate cancer four years ago, he talked his options over with Dr. O'Reilly. "When I first got a diagnosis of prostate cancer, it took over my life for awhile," says Snook, now 68 years old. "I did research and found out most men with prostate cancer don't die of the disease."
He and Dr. O'Reilly discussed the treatment options, including active surveillance, surgery and radiation. "We talked about the possible side effects of prostate cancer treatment, such as incontinence and erectile dysfunction. I decided that active surveillance was a good choice for me," Snook says. "Dr. O'Reilly assured me that if I changed my mind later on, we could change the treatment plan."
In the first two years of active surveillance, Snook had several biopsies. In the past several years, he has had MRIs and blood tests to assess his prostate cancer. There has been no significant change.
Snook believes that having a good relationship with your doctor is key to the success of active surveillance. "I have a lot of trust in Dr. O'Reilly. I know that if there were big changes in my prostate cancer, he would give me my options, and we would makes changes in my treatment plan," he says.
"I feel very comfortable with active surveillance," Snook adds. "It allows you to live your life and in my case, enjoy my retirement. You're monitoring your prostate cancer, but it's not taking over your life. I think about it two to three times a year when I go in for an appointment, but I'm not overly concerned about it in between appointments."
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