Low Risk Prostate Cancer May Not Need Treatment
- Prostate cancer is divided into risk categories based on how aggressive it is.
- These risk categories are: very-low-risk, low-risk; favorable-intermediate-risk, unfavorable-intermediate-risk; high-risk, and very-high-risk.
- Based on the cancer’s risk level, doctors might recommend active surveillance for low-risk prostate cancer or various treatments such as surgery, radiation, hormone therapy, or a combination thereof for more aggressive cases.
Although there are numerous treatments available for prostate cancer, what your doctor recommends will depend on what category of risk your disease falls under. Sometimes that may mean doing nothing at all.
How is prostate cancer staged?
Read More- Very-Low-Risk (VLR) and Low-Risk (LR)
- Favorable- (FIR) and Unfavorable-Intermediate-Risk (UFIR)
- High-Risk (HR) and Very-High-Risk (VHR)
PSA test:
A Prostate-Specific Antigen test is a blood test used primarily to screen for prostate cancer. It measures the level of PSA, a protein produced by both cancerous and noncancerous tissue in the prostate, a small gland that sits below a man’s bladder.
Elevated levels of PSA can indicate prostate cancer, although they can also be caused by other prostate conditions like infection or inflammation. PSA levels under 4 ng/mL are usually seen as normal where levels above 4 typically require additional workup.
Gleason test:
A grading system used to evaluate the aggressiveness of prostate cancer by examining prostate tissue samples taken in a biopsy under a microscope. Pathologists look at the patterns of cancer cells in the tissue and assign a score based on how much the cancerous tissue differs from normal prostate tissue.
Gleason scoring assigns two scores, ranging from 0-5. Combined they make up the total Gleason score. A Gleason score of 6 is the lowest, while 10 is the highest score possible for prostate cancer.
RELATED: Prostate Cancer: Overview
Very-Low-Risk (VLR) and Low-Risk (LR) Prostate Cancers
Prostate cancers classified as VLR or LR represent the least aggressive forms of cancer. This categorization will be diagnosed depending on number of factors, including:
- Your doctor can’t feel the cancer on a physical exam, or it occupies one-half or less of one side of the prostate
- Your PSA is less than 10
- Your total Gleason score is 6
If your cancer is categorized as VLR or LR, your doctor may recommend active surveillance, which is sometimes called “watch and wait.”
Dr. Nicholas Nickols, a radiation oncologist at the UCLA Department of Radiation Oncology, summarizes active surveillance as follows, ‘We carefully monitor the prostate cancer for evidence of progression or not, and then initiate treatment later, if at all.”
During active surveillance, you won’t receive any treatment but your doctor will key an eye on your cancer with a series of tests including:
- PSA Levels
- MRIs
- Repeat biopsies
It’s possible that your cancer may never progress to more aggressive forms of prostate cancer. Active surveillance should help your doctor catch any changes or progression.
RELATED: What is Active Surveillance?
Patients on active surveillance can be spared the side effects of pursuing the traditional ways of treating prostate cancer. If and when the disease becomes more aggressive, as indicated by a rising PSA, development of aggressive-looking disease on MRI, or increasing Gleason score, it can then be treated with surgery, radiation, hormone therapy, chemotherapy, or a combination of these therapies.
Favorable- (FIR) and Unfavorable-Intermediate-Risk (UIR) Prostate Cancer
“Some prostate tumors are neither considered aggressive nor non-aggressive; they’re in the middle… [Such cancers are termed] intermediate-risk prostate cancers. Sometimes it makes sense to watch them [when they are favorable], sometimes it makes sense to treat them[when they are unfavorable],” explains Dr. Nickols.
The specific criteria for intermediate-risk prostate cancer may vary slightly depending on the medical guideline your doctor follows. But according to the NCCN, patients with the following features can be classified as intermediate-risk:
- Cancer occupies one-half or both sides of the prostate
- Your PSA is between 10 and 20
- Your total Gleason score is 7
Intermediate-risk cancers can be further broken down into favorable (FIR) or unfavorable (UIR) categories.
FIR behaves less aggressively than UFIR and may even be treated with active surveillance in the correct setting. However, most men with FIR still receive local treatment to cure the disease.
When deciding whether active surveillance is appropriate for FIR prostate cancers, oncologists may order molecular testing.
For example, a Decipher genomic score, analyzes the genomic characteristics of a patient’s prostate biopsy and rates it on a scale of 0-1, with 0 representing less aggressive and 1 representing the more aggressive cancers.
If a patient with FIR disease has a low Decipher score, doctors may recommend active surveillance as the way to manage the disease. However, cancers in this category may progress to more aggressive forms at a higher rate than those that fall into the lower risk category.
RELATED: The Challenge of Deciding When to Treat Prostate Cancer
Doctors almost always recommend further evaluation for unfavorable intermediate-risk prostate cancers. They usually recommend treatment which may include surgery or radiation therapy with hormone therapy, or a combination of the two.
High-Risk (HR) and Very-High-Risk (VHR)
HR and VHR prostate cancers are the most aggressive forms of the disease. The criteria for HR and VHR cancers include:
- Cancer that has spread beyond the prostate and may involve other parts of the body
- Your PSA is more than 20
- Your Gleason score is between 8 and 10
“Some prostate cancers are aggressive, and we consider them to be HR,” Dr. Nickols says.
“That means that there is a high risk of spreading, and… definitive treatment is recommended. The definitive treatment is either surgical removal of the prostate [and lymph node removal] or radiation therapy, which is directing X-rays to irradiate the prostate, in combination with hormone therapy,” he adds.
Aggressive prostate cancers diagnosed as high risk carry a significantly increased potential for spreading. They should never be managed with active surveillance. Doctors almost always recommend treatment right away for high risk prostate cancer.
Depending on specific factors, treatment may consist of one or a combination of the following:
- Surgery
- Radiation with hormone therapy for HR
- Radiation with intensified hormone therapy for VHR cancers
Questions to ask your doctor:
When you are diagnosed with prostate cancer, your care team at the VA will be there to answer all of your questions. You might consider asking;
- What is the risk category of my prostate cancer?
- Is active surveillance an appropriate option for me?
- If not, what are my treatment options?
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