Posts Tagged ‘active surveillance’

Prostate Cancer Update 2017: A More Nuanced Approach

December 3, 2016

Andrew Siegel MD  12/3/2016

prostate_cancerAttribution of above image: Blaus (Own work) [CC BY-SA 4.0 (, via Wikimedia Commons

It was not so long ago that all prostate cancers were lumped together, the thought being that a cancer is a cancer and best served by surgical removal. Consequently, with the best of intentions, some unnecessary surgical procedures were performed that at times resulted in impaired sexual function, poor urinary control, and unhappy patients.

Fortunately, urologists have become wiser, recognizing that individual prostate cancers are unique and that a nuanced approach is the key to proper management. Some prostate cancers are so unaggressive that no cure is necessary, whereas others are so aggressive that no treatment is curative. One thing is for certain—we have vastly improved our ability to predict which prostate cancers need to be actively treated and which can be watched.

The Challenge Of Diagnosing Prostate Cancer

The vast majority of patients who have undiagnosed prostate cancer have NO symptoms—no pain, no bleeding, no urinary issues, no anything. The possible diagnosis of prostate cancer is usually entertained under three circumstances: when there is an elevated PSA (Prostate Specific Antigen) blood test; when there is an accelerated PSA (when the change in PSA compared to the previous year is considered to be too high); and when there is an abnormal prostate DRE (digital rectal exam)—a bump, lump, hardness, asymmetry, etc. The bottom line is that if you don’t actively seek prostate cancer, you’re not going to find it. When prostate cancer does cause symptoms, it is generally a sign of locally advanced or advanced prostate cancer. Therein lies the importance of screening.

The Dilemma Of Screening For Prostate Cancer

The downside of screening is over-detection of low risk prostate cancer that may never prove to be problematic, but may result in unnecessary treatment with adverse consequences. The downside of not screening is the under-detection of aggressive prostate cancer, with adverse consequences from necessary treatment not being given.

How Is The Diagnosis of Prostate Cancer Made?

When the PSA is elevated or accelerated and/or if there is an abnormal prostate DRE in a reasonably healthy man with good longevity prospects, an ultrasound-guided prostate biopsy is in order. Obtaining tissue for an exam by a pathologist is the definitive and conclusive test. The biopsy will reveal if cancer is present and its location, volume and grade (aggressiveness).

If prostate cancer is present, it is useful to determine the risk potential of the prostate cancer (“risk stratify”) by classifying it into categories based upon the following:

T (Tumor) category

T1c: cancer found because of PSA elevation or acceleration with a normal DRE

T2a: palpable (that which can be felt on DRE) cancer of half or less of one side

T2b: palpable cancer of more than half of one side

T2c: palpable cancer of both sides

T3a: cancer outside prostate, but sparing the seminal vesicles (reproductive structures that store semen)

T3b: cancer involving seminal vesicles

T4: regional spread of cancer to sphincter, rectum, bladder or pelvic sidewall

Gleason Score

Dr. Gleason devised a system that grades prostate cancer by observing the cellular architecture of prostate cancer cells under the microscope. He recognized that prostate cancer grade is the most reliable indicator of the potential for cancer growth and spread. His legacy, the grading system that bears his name, provides one of the best guides to prognosis and treatment. The pathologist assigns a separate numerical grade ranging from 3 – 5 to each of the two most predominant patterns of cancer cells. The sum of the two grades is the Gleason score. The Gleason score can predict the aggressiveness and behavior of the cancer, with higher scores having a worse prognosis than lower scores.

Grade Group 1 (Gleason score 3+3=6)

Grade Group 2 (Gleason score 3+4=7)

Grade Group 3 (Gleason score 4+3=7)

Grade Group 4 (Gleason score 4+4=8)

Grade Group 5 (Gleason score 4/5+4/5=9 or 10)

The significance of the Gleason Grade Group can be understood by examining the PSA five years after surgical removal of the prostate, correlating survival with the Grade Group. Ideally, after surgical removal of the prostate gland the PSA should be undetectable. A detectable and rising PSA after surgical removal is a sign of recurrent prostate cancer. The five-year rate of PSA remaining undetectable (biochemical recurrence-free progression) for surgical removal of the prostate in Grade Groups 1-5 is the following: 96%, 88%, 63%, 48%, and 26% respectively, indicating the importance of the grading system with respect to prognosis.

Number cores with cancer

Generally 12 – 14 biopsies are obtained, occasionally more. In general, the more cores that have cancer, the greater the volume of cancer and the greater the risk.

Percent of tumor involvement (PTI)

The percentage of any given biopsy core that has cancer present. In general, the greater the PTI, the greater the risk.


PSA is an excellent “tumor marker” for men with prostate cancer. In general, the higher the PSA, the greater the risk category.

PSA density

The relationship of PSA level to size of the prostate, determined by dividing the PSA by the volume of the prostate. The volume of the prostate is easily determined by ultrasound or by MRI (magnetic resonance imaging). A PSA density > 0.15 is greater risk.


Risk Stratification For Prostate Cancer

Based upon the aforementioned parameters, an individual case of prostate cancer can be assigned to one of five risk categories ranging from very low risk to very high risk. This risk assignment is helpful in predicting the future behavior of the prostate cancer and in the decision-making process regarding treatment.

Very Low Risk: T1c; Gleason score ≤ 6; fewer than 3 cores with cancer; less than 50% of cancer in each core; PSA density < 0.15

Low Risk: T1-T2a; Gleason score ≤ 6; PSA < 10

Intermediate Risk: T2b-T2c or Gleason score 7 or PSA 10-20

High Risk: T3a or Gleason score 8-10 or PSA > 20

Very High Risk: T3b-T4 or Gleason grade 5 as the predominant grade (the first of the two Gleason grades in the Gleason score) or > 4 cores Gleason score 8-10


Prostate Cancer Treatment

Prostate cancer treatment is based upon risk category and life expectancy and includes the following:

RALP (robotic-assisted laparoscopic prostatectomy): surgical removal of the prostate gland using robotic assistance

RT (radiation therapy): this can be used as definitive treatment or alternatively for recurrent disease after RALP or immediately following healing from RALP under the circumstance of adverse pathology report

ADT (androgen deprivation therapy): a means of decreasing testosterone level, since the male sex hormone testosterone stimulates prostate growth

AS (active surveillance): actively monitoring the disease with the expectation to intervene with curative therapy if the cancer progresses. This will involve periodic DRE, PSA, MRI, and repeat biopsy.

Observation: monitoring with the expectation of giving palliative therapy (relieving pain and alleviating other problems that may surface without dealing with the underlying cause)  if symptoms develop or a change in exam or PSA suggests that symptoms are imminent.


Prostate Cancer Treatment Based Upon Risk Stratification

Very Low Risk

< 10 year life expectancy: observation

10-20 years life expectancy: AS

> 20 years life expectancy: AS or RALP or RT

Low Risk

<10 years life expectancy: observation

>10 years life expectancy: AS or RALP or RT

Intermediate Risk

<10 years life expectancy: observation or RT + ADT 4-6 months

>10 years life expectancy: RALP or RT + ADT 4-6 months

High Risk

RALP or RT + ADT 2-3 years

Very High Risk:

T3b-T4: RT + ADT 2-3 years or RALP (in select patients) or ADT

Lymph node spread: ADT or RT + ADT 2-3 years

Metastatic disease: ADT

Bottom Line: Excluding skin cancer, prostate cancer is the most common cancer type in men, accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk. The median age of prostate cancer at diagnosis is the mid 60s and in 2015 there were 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are currently about 2.5 million prostate cancer survivors in the USA.  It is important to diagnose prostate cancer as early as possible in order to decide on the most appropriate form of management—whether it is surgery, radiation, or observation/monitoring. Risk stratification can help the decision-making process.

“Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which will most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.”

Willet Whitmore, M.D.

(Dr. Whitmore served as chief of urology for 33 years at what is now Memorial Sloan-Kettering Cancer Center. He died of prostate cancer at age 78 in 1995.)

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health






Must My Prostate Cancer Be Treated?

January 4, 2014

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.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like.”

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in  2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.


Screening For Prostate Cancer Revisited

December 14, 2013

Blog # 132

The ignoramuses at the United States Preventive Services Task Force (USPSTF) gave Prostate Specific Antigen (PSA) testing a grade “D” recommendation and called for the complete abandonment of the test for prostate cancer screening.

Having lived and worked deep within the trenches of urology for over 25 years, I almost stroked when I read their recommendation. I previously crafted video responses:

and gave a “horse’s ass” award to the USPSTF in another video:

The Prostate Cancer World Congress took place in Melbourne Australia in August of 2013, where experts proposed a consensus view on the early detection of prostate cancer.  This material was published in the British Journal of Urology International.

The consensus was engendered by the great confusion generated after the USPSTF called for the total abandonment of PSA testing. The international experts who wrote the consensus statement included 14 international experts on prostate cancer, unlike the USPSTF, where there was not a single urologist on the committee.

The experts at the Prostate Cancer World Congress adopted the following five statements:   

  1. For men age 50–69, evidence demonstrates that PSA testing reduces death from prostate cancer by 21% and the incidence of metastatic prostate cancer by 30%.
  2. Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.  In other words, not everyone with prostate cancer will need to be actively treated and the potential side effects of active treatment should not influence the diagnosis of prostate cancer by the proper means.
  3. PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.  The experts proposed the use of prostate examination, family history, ethnic background, prostate volume, as well as a variety of risk models based upon PSA.
  4. Baseline PSA testing for men in their 40s is useful for predicting the future of prostate cancer. Men with baseline values that are high need further PSA testing.
  5. Older men in good health with over a 10-year life expectancy should not be denied PSA testing on the basis of their age.   This population of older men may certainly benefit from the early diagnosis of aggressive prostate cancers. This does not pertain to men with numerous other significant medical problems, but a healthy man in his mid-70s should not be denied PSA testing that might identify a cancer that has the potential to destroy his quantity and quality of life.  (In particular, the older man who comes to the office accompanied by his father should certainly not be denied!)

The consensus was that we should maintain the gains that have been made over the years since PSA was introduced—in terms of decreasing the number of men diagnosed with prostate cancer metastases (cancer that has spread) and reducing prostate cancer deaths—while minimizing the potential harms of over-diagnosis and overtreatment by increasing the use of active surveillance protocols in those men with low-risk prostate cancer.   Abandoning PSA testing as recommended by the USPSTF would lead to a reversal of all gains made over the course of the past 30 years.  Well-informed men should be offered the opportunity for early diagnosis of prostate cancer. To quote Dr. Jay Smith:  “Treatment or non-treatment decisions can be made once the cancer is found, but not knowing about it in the first place surely burns bridges.”

My take on the subject of screening for prostate cancer:

I like to keep things simple…I believe in two rules that are appropriate for medicine as well as just about everything in life.

Rule # 1: Do no harm.

Rule # 2: Do good.

To apply these rules to the game of golf, for example, “do no harm” means staying out of trouble as much as possible, keeping the ball out of the woods, bunkers and water hazards.  “Do good” by hitting the ball accurately in terms of distance and direction and setting up the next shot.

Screening for prostate cancer involves taking a medical history, doing a rectal exam to check the contour and consistency of the prostate, and a simple PSA blood test. “Do no harm” is satisfied because these tests are in no way harmful to the patient and provide information that is helpful, particularly when done on a serial basis, noting changes over time.

If exam shows an irregularity of the prostate, if the PSA is elevated, or if the PSA has accelerated significantly over the course of one year in a reasonably healthy man who has at least a ten-year life expectancy, doing a prostate ultrasound and biopsy is indicated. This test does entail a small risk of bleeding and infection, but the potential benefits far outweigh the risks.  “Doing good” is satisfied by the knowledge provided by the biopsy—the reassurance that comes from a biopsy report that shows no cancer and the potential for cure if the biopsy shows cancer.  Furthermore, the specific biopsy results along with other factors can predict which cancers are low-risk, which are medium-risk, and which are high-risk, important considerations in terms of active treatment versus active surveillance.

Many men who are found to have low-risk prostate cancer (low PSA; minimum number of biopsies showing cancer; low-grade cancer as determined by the pathologist) can be followed without active treatment (active surveillance) and those at greater risk can be managed appropriately (surgery or radiation), and many cured, avoiding the potential for progression of cancer and painful metastases and death—all while weighing the benefits of intervention against the risks.  Death from prostate cancer is unpleasant to say the least, often involving painful metastases to the spine and pelvis and not uncommonly, kidney and bladder obstruction, and our charge as urologists is to try to not let this scenario ever come to fruition.

One of our fundamental goals as urologists is to screen for prostate cancer—

the most common cancer in men present in 17% of the population—and if present, to provide appropriate guidance to best maintain both quality and quantity of life.  Anyone who reads the obituaries knows that prostate cancer is a cancer that is lethal, and if you don’t read the obituaries, I can promise you that prostate cancer kills in unkind ways. Even though only 3% of the male population dies from prostate cancer, that amounts to many thousands of men annually… and you do not want to be one of them.  I have my own PSA and prostate exam done every year and PSA screening was responsible for making an early diagnosis of my father’s prostate cancer in 1997, which was cured by surgery, resulting in a healthy and thriving, cancer-free 82 year-old man who will never die from prostate cancer.

BOTTOM LINE: PSA remains an invaluable screening tool for the detection of prostate cancer and ALL men ages 50 and over (40 if there is a family history) should be tested…IT JUST MAY SAVE YOUR LIFE!

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like.”

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.