Cancer Insights: Active surveillance is not avoiding the issue
September 22, 2014 | by Jonathan Yamzon M.D.
Jonathan Yamzon, M.D., assistant clinical professor of surgery in the Division of Urology and Urologic Oncology, explains his approach to what's known as "active surveillance" of men with prostate cancer. Patients need to be educated about their treatment options, he writes.
Active surveillance is an option offered to patients with "low-risk" prostate cancer. It entails forgoing any immediate treatment, and instead monitoring a patient’s cancer to ensure it shows no signs of worsening. If there are any signs of disease progression, the option for curative treatment can still be offered. Active surveillance attempts to avoid unnecessary treatments for patients with prostate cancers that may not become clinically significant or impactful to a man’s life.
Such treatments have potential risks for side effects. Those considered low-risk have a prostate specific antigen (PSA) value of less than 10, a biopsy Gleason of six or less, and a rectal exam that reveals nothing beyond a small nodule confined to one side of the prostate. When one of my patients embarks on active surveillance, I repeat the PSA, rectal exam and biopsy to ensure that their tumor is in fact truly low-risk. The success of this strategy is predicated on recurring follow-ups and reassessment to detect worsening changes of the tumor grade, volume or stage. It is important to understand that if there are signs of cancer progression, we can still offer treatment with curative intent.
Currently, our ability to stratify who is low-risk is based on clinical parameters of the PSA, Gleason score and clinical stage, which is detected by a rectal exam. Newer biomarkers are being studied to improve risk stratification, including the use of novel markers in serum, urine, biopsy tissue and radiographic test like magnetic resonance imaging (MRI).
Active surveillance is not putting your head in the sand. It is not avoiding the issues. If done correctly and if patients keep consistent follow-ups, we shouldn’t miss any signs of disease progression. The concern with not being treated immediately is that patients feel they are going to miss the opportunity to eradicate the disease in its early localized confined stage. If active surveillance is done properly, it is not going to be too late for curative treatment.
I usually repeat a patient’s PSA every three months, more frequently than the National Comprehensive Cancer Network recommends, which is six months. I personally like to get more data points to examine variability, but it varies with every practitioner, and understandably so, because at this point, the uptake of active surveillance in the medical community across the country is about 10 percent.
I typically get questions about biopsies. The patterns of biopsies are different. For example, if someone receives a diagnosis of "low-risk" prostate cancer with a small tumor focus, some cancer centers will have the patient biopsied in one year, and other cancer centers will have the patient biopsied a lot sooner. As a physician, we concern ourselves with the sampling error of a biopsy, namely missing something significant. With each biopsy sample, we are examining a small quantity of the prostate, and a minimum of 12 samples are obtained across the entire prostate. There is potential to miss a tumor. We now incorporate the use of an MRI to help discern areas in the prostate suspicious for tumor. The MRI may guide us when we perform biopsies.
Because of sampling issues, I like to rebiopsy my patients sooner rather than later, performing what is called a confirmatory biopsy. This is usually done within six months of the original biopsy. If the repeat biopsy shows the same results, then I usually wait one to two years to do another biopsy. However, if the patient’s PSA starts to rise, the rectal exam becomes suspect or a repeat MRI shows an area of potential tumor, we will repeat the biopsy sooner.
Sexual function: Active surveillance vs. surgical treatment
So what do you do with a young potent 55-year-old male diagnosed with prostate cancer? One argument in favor of active surveillance is that he is young, sexually active and has minimal urinary symptoms, so why risk compromising his quality of life with treatment on a cancer that is currently nonlife-threatening? One can easily be followed and treatment can be offered later if and when the cancer appears significant. This approach would attempt to maximize his quality of life. The counter argument is that because he is so young and expected to easily live another 20 years, one may be delaying the inevitable. He has at least 20 years for this cancer to progress, so why not treat him now while he is young, healthy and in a better position to make a full recovery? I pose both arguments to all my patients and offer active surveillance up front, and treatment to anyone not accepting of the active surveillance approach.
There are many factors that contribute to the recovery of potency, both surgical factors and underlying patient health factors. The preservation of the neurovascular bundles during surgery is routinely done unless someone has a large tumor worrisome for extension beyond the prostate capsule. In principle, I can put a low-risk patient on active surveillance and minimize any disturbances to their quality of life, and offer them definitive therapy later on if needed. On the other hand, some can make the argument that disease detected early in a young male with a long life expectancy is surely to progress in that man’s lifetime, and he should get the surgery done while he is young, healthy and has a better chance of recovering completely. The approach and recommendations are handled on a case-by-case basis.
Emotional effects of active surveillance
With patients, there is a lot of anxiety associated with active surveillance. I recently had a 65-year-old patient in overall good health who exercises regularly, and he was diagnosed with a very "low-risk" prostate cancer. After doing two biopsies, prostate cancer was found in a very small focus, entailing less than 5 percent of the biopsy. I told him, after doing a couple of tests, that active surveillance was right for him, and suggested he come back to get another biopsy in six months, but about a month later he said that he just wanted the surgery. Again, I tried to explain to him why he was a candidate for active surveillance, reaffirming my recommendation even on the day of surgery, but he was too anxious to stay on active surveillance. Sure enough, once we had the specimen analyzed, he had a low-grade disease that was confined to the prostate.
This type of situation isn’t that common among my patients who are candidates, but most patients who are eligible for active surveillance tend to be amenable to it. If you speak to them about the data behind active surveillance and educate them, they will have a better understanding of the choice they are making. I also make sure that these patients are reliable and willing to commit to recurring follow-up appointments and tests, so I can measure and watch for signs of progression. The success of active surveillance is predicated on continued follow-up.
Importance of health check-ups
Keeping an eye on your personal health and getting check-ups yearly are necessary and could be lifesaving. For prostate screenings, which includes a PSA test and digital rectal exam, it is recommended to begin screenings at 55 years old. For those interested in early detection, I recommend getting one every two years. Keep in mind that family history of prostate cancer is a risk factor, so if your father or brother had it, we recommend getting screened at an earlier age.
When you catch prostate cancer and treat it early you can minimize the impact to your quality of life. I see men that come in with very advanced prostate cancer where surgery is not an option for them anymore, so they embark on hormone therapy or radiation. For many, their PSA tests are very high. For example, I saw a patient recently who was 54 years old, finally getting an annual checkup and his PSA was in the 100s, which is extremely high. His scans confirmed metastatic disease and at this point he is not a candidate for surgery. Regular check-ups may have detected his disease earlier.
Keep an eye on your health, ask your doctor questions and understand the importance of prostate health.
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