What is Active Surveillance?

Prostate cancer is the most diagnosed cancer in men and fortunately due to multiple effective treatment options has a favorable prognosis. The most common and effective treatments for prostate cancer are radiation therapy and surgery. Despite their effectiveness, these treatments are associated with side effects. Specifically, radiation can cause erectile dysfunction, urinary frequency and urgency, and changes in bowel habits. Surgery also causes erectile dysfunction but also can cause urinary incontinence and urinary leakage.

Given that these side effects can significantly impact the quality of life it is important to only treat prostate cancer when it is necessary to avoid these potential complications.

Dr. James Brooks explains the benefits of the ‘active surveillance’ approach.

Who is a candidate for active surveillance?

Not all men with prostate cancer are potential candidates for active surveillance. Active surveillance is only recommended for men with low-risk prostate cancer who are capable and willing to follow a very close and active follow-up schedule. Low-risk prostate cancer is slow growing and is biologically less aggressive compared with higher-risk prostate cancer. Dr. Stephen Freedland, a urologist at Cedars-Sinai Medical Center says:

"With low-risk prostate cancer, your risk of cancer getting out of the prostate and spreading to other parts of the body is really, really low."

Men who have low-risk cancer can choose this approach and avoid the potential complications that come with treatment with surgery and radiation. Because the risk of the cancer spreading outside of the prostate is extremely low in men with low-risk disease, this approach is an effective option for men.

A large randomized study showed that there was no difference in survival among men with low-risk prostate cancer who either had active surveillance, surgery, or radiation treatment. More importantly, this same study showed that men who had active surveillance had fewer side effects and a better quality of life compared with surgery. Additionally, about 50 percent of the men randomized to active surveillance were able to avoid treatment completely.

What is involved with active surveillance?

As we mentioned active surveillance is a very active protocol that allows your cancer team to closely monitor the cancer for changes. This approach usually involves a PSA test every 6 months, repeat digital rectal examinations no more frequently than every year, and repeat biopsies no more frequently than every year. Other tests may also be used such as advanced imaging with prostate MRIs, prostate MRI-fusion biopsies, and even genetic testing such as the Decipher genomic analysis. All of these tests are designed to monitor the cancer and catch any change early.

What would indicate treatment is needed?

As discussed half of men who choose this approach will avoid unnecessary treatment and side effects. This means that about half of men will need treatment. Multiple factors can trigger treatment. First, if you decide you want the cancer treated and are tired of the active protocol this is an excellent reason to initiate treatment.

Dr. Geoffrey Sonn explains how the decision to begin treating prostate cancer is made. 

Outside of patient preference other factors that would indicate the cancer is growing or becoming more aggressive include a rising PSA, an increasing Gleason score, or a change felt on examination or seen on an MRI. Because prostate cancer is highly curable with surgery or radiation, and outcomes are better when it is treated sooner any factor that indicates the cancer is growing or becoming more aggressive may provide evidence that treatment is needed.

The take-home message

Active surveillance is a great option for men with low-risk prostate cancer who can follow a very active follow-up protocol. Active surveillance allows about 50 percent of men to avoid over-treatment and side effects. The protocol is designed to identify early signs of cancer growth or an increase in aggressiveness and these factors will indicate treatment is necessary.

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