One of the biggest decisions you will need to make if you are diagnosed with prostate cancer, is how to proceed.
Should you get treatment? Or is it better to leave the cancer alone and monitor it, an approach known as active surveillance?
Read MoreWhy should I consider active surveillance?
All treatments for prostate cancer, no matter how effective, come with the risk of side effects. Often this includes issues with sexual function and bladder health. When your doctor recommends the ‘watch and wait’ approach, it means you can put off or even completely avoid treatment and sidestep the accompanying side effects.Keeping a close watch on the cancer increases the chances of spotting changes quickly and treating if necessary.
When does active surveillance make sense?
Active monitoring is the best choice for patients who are diagnosed with low-risk, localized prostate cancer.
Watch and wait is particularly recommended for patients whose cancer is:
- Small
- Expected to grow very slowly
- Confined to one area of the prostate
- Not causing any signs or symptoms.
- Gleason score of 6
Doctors sometimes recommend that patients with a Gleason score of 7 also consider this approach. However, in this case, doctors will usually recommend closer and more frequent monitoring due to a slightly higher risk.
“We have a vast wealth of information saying that treating those cancers is actually over-treatment, they do not pose metastatic potential,” notes Dr. Wysock.
“And that’s another very important part of my diagnosis and discussion is that, look, this is a low risk disease that we’ve detected and I do not think it’s going to harm you and therefore I want you to be reassured that what we’re going to do is monitor this,” he adds.
Watch: Dr. James Brooks discusses the pros and cons of active surveillance in prostate cancer
What are the pros and cons of active surveillance?
You and your doctor will need to weigh the risks and benefits of active surveillance to see if it makes sense for you.
Benefits:
- No treatment side effects common with treatment such as urinary incontinence, erectile dysfunction, and bowel issues.
- Better quality of life, particularly in terms of sexual function and bladder health.
- More time to make informed decisions about if and when to begin treatment.
Risks:
- Living with untreated cancer can be stressful
- Frequent Testing and regular doctor visits can be time-consuming and disruptive.
- There’s a risk that the cancer may grow or become more aggressive during the surveillance period. This may reduce the effectiveness of treatment.
- There’s still a risk that patients will have treatment they don’t need due to changes in test results
Deciding on active surveillance involves careful consideration of these factors, Dr. Wysock explains. Regular follow-ups to monitor the cancer closely is a must to stay on top of changes that require treatment.
Dr. Wysock sums it up this way: “Catch it early, catch it small, and then be able to enact many different pathways.”
When does it make sense to move from active surveillance to treatment?
About 50% of men who opt for active surveillance will have changes within five years that require active treatment.
Doctors may recommend switching to treatment based on specific criteria:
- PSA levels: A rapid increase or a level consistently higher than the typical range for age may signal the need for intervention.
- Digital rectal exam findings: Detection of new or enlarging nodules could indicate cancer growth.
- Gleason Score: An increase in Gleason score, particularly to 7 or above, from repeat biopsies suggests more aggressive cancer.
Read on for definition of these terms plus other terms you’ll hear through diagnosis and treatment.
Related: When Active Surveillance Isn’t Enough
What role does testing play in guiding prostate cancer management?
“The entire diagnostic pathway for prostate cancer is fraught with complex discussion, complex issues,” Dr. Wysock notes, adding that often the decision to treat or not to treat is based on an array of tests your doctor will order.
In managing prostate cancer, particularly under active surveillance, your doctor will review various tests to guide this critical decision:
- Cancer staging with the TNM System: This system categorizes cancer based on Tumor size (T), lymph Node involvement (N), and Metastasis (M). T stages range from T1 (cancer not visible on imaging or palpable during examination) to T4 (cancer has spread to nearby organs). N and M stages assess the spread to lymph nodes and distant organs, respectively, crucial for determining treatment strategies.
- Gleason score: Using tissue from a biopsy, this test grades cancer from 6 (less aggressive) to 10 (most aggressive), and a measurement of PSA levels to gauge cancer’s likelihood of progression.
- PSA Test: This blood test measures the level of prostate-specific antigen (PSA), with higher scores potentially indicating the presence of prostate cancer or other prostate conditions.
- Multiparametric MRI (mpMRI): Provides detailed images for assessing tumor size and guiding biopsies. Helps both staging and risk assessment.
If your cancer is considered low-risk and localized, your doctor will probably recommend active surveillance that involves monitoring at regular intervals which will involve repeating some or all of the above tests.
“…if we are able to detect the prostate cancer at a very early stage and a low volume, we have many different options for managing it and higher expectations of that prostate cancer will be completely controlled. And so as we continue to improve our diagnostic tests and our diagnostic paradigms, that’s the ultimate goal,” Dr. Wysock says.
Related: What Happens If My PSA Is Elevated?
Questions for your doctor
- Is my cancer suitable for active surveillance?
- How often will I need testing during surveillance and what tests will I have?
- What signs indicate that my cancer is progressing?
- How quickly can we switch to treatment if needed?
- What costs related to surveillance are covered by insurance and what are my copays?
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