Is Active Surveillance for Prostate Cancer Safe and Effective?

As recently as a decade ago, a man diagnosed with any prostate cancer might be recommended for surgery or radiation therapy, according to the National Cancer Institute. That included lower-grade, less-aggressive types with a low risk of imminent death.

The approach no doubt saved the lives of patients who did have unidentified dangerous forms of prostate cancer. It also resulted in many men developing lifelong urinary or erectile issues as a result of overly aggressive treatment that may not have been necessary.

Today, the men's health community generally takes a more nuanced, restrained approach that includes, when possible, active surveillance. Urologic oncologists and pathologists have more precise tools and techniques to assess and diagnose prostate cancer lesions. They're better able to differentiate dangerous, fast-growing cancer from the slow-growing kind.

As a result, many men are opting for less aggressive treatment. Instead, they are working with their healthcare providers to closely monitor the cancer and delay treatment until there is evidence it has advanced.

This is known as active surveillance, and it's a prostate cancer treatment regimen that's becoming more common. Why is this non-treatment treatment on the rise? What do studies suggest regarding it? Why is it OK to actually leave some prostate cancer alone?

Who's a candidate for active surveillance?

In order to be a good candidate for active surveillance, a patient must have low-grade cancer (with occasional exceptions made for intermediate-grade cancer). A low-grade cancer is one that registers at a Gleason 6. The Gleason scale is a grading system used to determine prostate cancer's aggressiveness, or its tendency to grow and spread.

Low-grade cancers are defined as "well-differentiated," which means they tend to be less aggressive and grow slowly. Good candidates must also have a prostate-specific antigen (PSA) test value of 10 or less that doesn't change much over time.

Then, if a confirmatory biopsy and subsequent PSA test confirm these values, and if certain genomic markers confirm the likelihood of low-grade cancer, the patient will likely be given the option of active surveillance.

"We know the vast majority of men will develop prostate cancer if they live long enough," said Vignesh T. Packiam, M.D., a urologist and clinical assistant professor of cancer and urology at University of Iowa Health Care. "But very few men develop aggressive or lethal prostate cancer. Thus, our goal is to treat significant prostate cancer and avoid over-treatment for less serious prostate cancer, especially if almost everyone is destined to develop it."

What does active surveillance look like?

The specifics of active surveillance vary from clinic to clinic. Generally, it means eschewing more aggressive forms of treatment, such as surgery and radiation, and doing periodic testing to confirm that nothing has changed.

Even some aspects of the testing and its frequency have been reconsidered by some professionals in the men's healthcare community.

"Active surveillance allows us to safely monitor low- and some intermediate-risk cancers with modern technology, which these days includes MRI, fusion biopsies, genomic markers and other biomarkers," Packiam said. "There is also a recent push to 'de-escalate' active surveillance and do biopsies only when needed, and less often."

A regimen of ongoing PSA, biopsy and MRI testing might sound like a lot. Consider, however, that the alternatives carry a high risk of morbidities such as erectile dysfunction (ED) and urinary incontinence.

"Historically, even the Grade group 1, which are the least aggressive type, those might have always been managed with some kind of treatment like surgery or radiation," said Petar Bajic, M.D., a urologist and men's health surgical specialist at Cleveland Clinic. "But nowadays, the vast majority of men, particularly those that have small amounts of Grade 1 prostate cancer, are managed very successfully with active surveillance."

The research

At first glance, it might seem alarming to simply carry on with your life knowing there's cancer inside you, even a slow-growing one that's not an immediate threat. It may put some patients' minds at ease to know recent research has shown active surveillance results are quite successful.

One meta-study from the University Health Network (UHN) of the University of Ontario, Canada, analyzed data from 21,282 men who were diagnosed with low-grade prostate cancer between 2002 and 2014. Some were given initial treatment and some were put on active surveillance. The results were revealing. The 10-year follow-up showed that:

• Metastasis-free survival was 94.2 percent.
• Overall survival was 88.7 percent.
• Cancer-specific survival was 98.1 percent.

That final figure—less than 2 percent of the men died of cancer in the ensuing decade after being put on active surveillance—makes it difficult to dispute that the modality has efficacy. It's even better when you consider the positive quality-of-life factors—sexual and urinary among them—for the men who got to keep their prostate glands.

"This study adds to other high-quality data that active surveillance is safe for most folks with low- and some with favorable intermediate-risk prostate cancer," Packiam said. "Accurate risk stratification is the primary consideration for whether or not to go on active surveillance."

Conclusions

Being told you have cancer but that one option is to leave it alone can be a scary prospect. In fact, many men given the option of going on active surveillance choose a more aggressive intervention just to be relieved of that stress.

Modern advances and studies like the one UHN researchers conducted have suggested that, at least for those who are willing and able to live with it, prostate cancer is something you can die with, not die from. Progress continues, even beyond what was demonstrated in the research.

"This study shows we can continue to refine active surveillance, and it's very possible that modern outcomes are superior," Packiam said. "While the study had a long follow-up, which is important for prostate cancer given its overall slow growth, the cohort was from 2002 to 2014. Since then, we have further refined patient selection and technology, including improved imaging, biopsy and biomarkers."