Prostate: Active Surveillance

Today’s topic is going to be about active surveillance. When it comes to any type of cancer, the first thought is to “get it out” of the patient. If you happen to see a Urologist, their solution is going to be to take a patient to surgery. If you speak to a radiation oncologist, his initial thought is going to be to treat you with Radiation Therapy, most likely IMRT. I am here to talk a little bit more about another option for a selected group of patients, which is referred to as Active Surveillance.
                  Historically, Surveillance meant that patients made the conscious decision to choose no definitive treatment for their prostate cancer. This was at times referred to as watchful waiting. The take on this method of watch and wait, was that the prostate cancer was going to grow and eventually it would spread. At the time of the cancer spreading, palliative or relief treatment options would be offered to the patient. Put another way in order to emphasise the differences between these two contrasting approaches, whereas watchful waiting involves relatively lax observation with late, palliative treatment for those who develop symptoms of progressive disease, active surveillance involves close monitoring with early, curative treatment in those with evidence of biochemical or histological progression.
However, I want to talk about a newer thought. Something more reasonable and better to offer to patients if they fall into this very specific class of patients, and if they decide that they do not want any definitive type of treatment at this point in time. That option is referred to as: Active Surveillance.
The rationale behind Active Surveillance is that by some estimations, up to 80% of PSA diagnosed prostate cancers are actually overdiagnosed. What this means is that of these prostate cancers that have been detected with PSA, that the majority of those cancers would never have progressed to a point that would have caused any harm or noticable effects to the patient.
Active surveillance was formally described for the first time in 2001 by Richard Choo from Toronto, in a report of ‘Watchful observation with selective delayed intervention for clinical, histologic, or PSA progression’. (Click here for this study.) 
In this study, men were selected and limited to only those with a clinical stage T1b-T2b prostate cancer. Gleason scores had to be equal to or less then 7, and the initial PSA lvel had to be equal to or less then 15. Men were then followed every three months for the first 2 years, and then at 6 months intervals there after with routine PSA and Digital Rectal Exams. Repeat biopsy was performed at 18 months after initial biopsy.
Indication for definitive treatment was then selected to be PSA progression or increase. This was defined as a doubling time (time it takes for PSA to incrase by a factor of 2) of less then 2 years. It was also defined by histological progression. This would mean that after 18months, with a new biopsy, that patients were then upstaged to a gleason score of 8 or greater. Clinical progression was taken into consideration as well.
The latest update of this data included 206 patients and that the average patient had a PSA of 6.5. At an average follow up of 29 months, 48 patients had received definitive treatment. Another 4 patients had died due to causes unrelated to their cancer diagnosis, and 154 men remained on observation with no progression of disease.
Another similar study was performed between 1993 and 2001 at the Royal Marsden Hospital. On their study they had 80 participants. Of those 80 participants on the Active Surveillance study, 10 patients received definitive treatment, 3 had died of causes unrelated to their cancer diagnosis, and 67 patients continue to be on observation to date.
In 2002, a similar study was then reintroduced by Royal Marsden Hospital of more then 200 men. Preliminary results of this clinical trial is suggesting that nearly 80% of the men enrolled will not need definitive treatment.
This is promising news for men that meet this criteria. If you happen to be a young, active male, that is diagnosed with an early stage prostate cancer, and the side effects from surgery and radiation are more then you are willing to bare currently, then there is promising hope that taking an active role in monitoring the disease will lead to overall cancer survival and better quality of life. If one makes this decision, patients will need to make sure that they meet on a regular basis with their physicians and are routinely screened for prostate cancer to check on potential of disease progression.
As of today, the recommendations for an Active Surveillance Prostate Cancer Screening Program are as follows: PSA +/- DRE every 3 months for first 2 years. Additional biopsy at 12-18months. After this, based off of the data you and your physician are armed with, you can get a good idea of how the prostate cancer is working specifically to you. At this time the decision can be made to continue every 3 months, or yo can push it back to every 6 months based off of progression of your disease to date.
This is not a statement or recommendation that everyone diagnosed with prostate cancer should not get treated. It is just another option for a selected group of men. If there were no side effects from Radiation or Surgery, then making the choice to have one of those treatments would be perfectly fine for all men across the board. Since we live in the real world, and every choice we make comes along with a set of circumstances, in this scenario, those circumstances are side effects. Active surveillance aims to individualize the management of early prostate cancer by selecting only those men with significant cancers for curative treatment.
For more information, or to answer any other questions or concerns you may have, please contact me at the following email address: CANCERGEEK@GMAIL.COM If you leave a phone number, I will call you back as well.

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