Blog # 135
“To do nothing, that’s something.”
…Samuel Shem, The House of God
Prostate cancer needs to be accorded respect as there are 240,000 new cases diagnosed annually and it accounts for 30,000 deaths per year, being the second leading cause of cancer death in men, only behind lung cancer.
Unlike many other malignancies, prostate cancer is often not a lethal disease and may never need to be treated. Shocking, right…a cancer that does not necessarily need to be cut out or managed in any way! Patients with slow-growing, early stage cancer as well as older men with other health issues may be put on surveillance, aka watchful waiting, as opposed to traditional treatment with surgery or radiation.
The problem is that not all prostate cancers are slow-growing and early stage, and the challenge is how to predict the future behavior of the cancer so as to treat it appropriately—offering cure to those with aggressive cancer, but sparing the side effects of treatment in those who have non-aggressive cancer. The goal of active surveillance is to allow men with low risk prostate cancer to avoid radical treatment with its associated morbidity and/or delay definitive treatment until signs of progression occur. This involves two things—vigilant monitoring and a compliant patient who is compulsive about follow-up.
The ratio of 7:1 of the lifetime likelihood of diagnosis of prostate cancer (about 1 in 6 men) to death from prostate cancer (about 1 in 40 men) points out that many men with prostate cancer have an indolent (i.e., slow growing) cancer. Because of this fact, an alternative strategy to aggressive management of all men with prostate cancer is active surveillance, a structured means of careful follow-up with rigorous monitoring and immediate intervention should signs of progression develop. Being a candidate for this approach is based upon the results of the PSA blood test, findings on the digital rectal exam, and the details of the biopsy, which usually involves obtaining one dozen samples of prostate tissue.
General eligibility criteria for active surveillance include all of the following (Note that these are basic guidelines and need to be modified in accordance with patient age and general health— certainly if one has a life expectancy < 10 years, he would be a good candidate for active surveillance, regardless of the following):
- PSA (Prostate Specific Antigen) less or equal to 10 (PSA is the blood test that when elevated or accelerated indicates the possibility of a problem with the prostate and is often followed by a prostate ultrasound/biopsy)
- Gleason score 6 or less (possible score 2-10, more about this below)
- Stage T1c-T2a (T1c = picked up by PSA with normal prostate on rectal exam; T2a = picked up by abnormal prostate on rectal exam, involving only one side of the prostate)
- Less then 3 of 12 biopsy cores involved with cancer
- Less then 50% of any one core involved with cancer
Prostate cancer grade is often the most reliable indicator of the potential for growth and spread. The Gleason score provides one of the best guides to the prognosis and treatment of prostate cancer and is based on a pathologist’s microscopic examination of prostate tissue. To determine a Gleason score, a pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells. The numbers range from 1 (the cells look nearly normal) to 5 (the cells have the most cancerous appearance). The sum of the two grades is the Gleason score. The lowest possible score is 2, which rarely occurs; the highest is 10. The Gleason score can predict the aggressiveness and behavior of the cancer. High scores tend to suggest a worse prognosis than lower scores because the more deranged and mutated cells usually grow faster than the more normal-appearing ones.
Prostate cancers can be “triaged” into one of three groupings based upon Gleason score. Scores of 2-4 are considered low grade; 5-7, intermediate grade; 8-10, high grade.
The active surveillance monitoring schedule is typically:
- PSA and DRE every 3-6 months for several years, then annually
- Prostate biopsies: one year after initial diagnosis, then periodically until age 80 or so (once again, a judgment call)
As long as the cancer remains low-risk, the surveillance protocol may be continued, sparing the patient the potential side effects of surgery or radiation.
Another meaningful way of predicting the behavior of prostate cancer is by using the PSA Doubling Time (PSADT)—defined as the amount of time it takes for the PSA to double. A short PSA doubling time is indicative of an aggressive, rapidly growing tumor, whereas a long PSA doubling time is indicative of an indolent, slow growing tumor. A PSADT of less than 3 years is clearly associated with the potential for progression of prostate cancer.
A change in plan from active surveillance to more active intervention needs to be instituted if any of the following occurs:
- PSA doubling time is noted to be less then 3 years
- Biopsy reveals grade progression to Gleason 7 or higher
- Biopsy reveals increased prostate cancer volume
Approximately half of men on active surveillance remain free of progression at ten years, and definitive treatment is most often effective in those with progression. The absence of cancer on repeated prostate biopsy (because the cancer is of such low volume) identifies men who are unlikely to have progressive prostate cancer.
Bottom Line: Active surveillance is an effective means of minimizing over-treatment of indolent prostate cancer and avoiding the side effects of immediate treatment. Its disadvantages are the need for frequent and repeated testing and biopsy, the anxiety of living with untreated prostate cancer, and the possibility that delayed treatment may not be curative, although that is not usually the case.
Andrew Siegel, M.D.
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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com
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Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in 2014.
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Tags: active surveillance, Andrew Siegel MD, digital rectal exam, Gleason score, prostate biopsy, prostate cancer, prostate malignancy, prostate specific antigen, prostate tumor, prostate ultrasound, PSA, radiation, radical prostatectomy, watchful waiting