National Comprehensive Cancer Network Reverses Prostate Cancer Guidance Following Medical Community’s Uproar About Active Surveillance Recommendations for Men With Low-Risk Disease

Its recommendation that active surveillance was no longer considered preferred for men with low-risk prostate cancer had oncologists and others in the medical community questioning the organization's thinking. (The NCCN recommended, at the time, that men with low-risk disease shouldn’t be managed with just active surveillance; it should be managed with radiation therapy or surgery as well, preferably a balance of all three.)

"New @nccn #prostatecancer guideline. AS (active surveillance) no longer 'preferred' for low-risk (prostate cancer)?! 🤦🏼‍♂️ #whiskytangofoxtrot #pcsm @wandering_gu @DrSpratticus,” Dr. Matthew Cooperberg, a professor of urology at the University of California San Francisco, posted to Twitter on Sept. 28.

New @nccn #prostatecancer guideline. AS no longer “preferred” for low-risk?! 🤦‍♂️ #whiskytangofoxtrot #pcsm @wandering_gu @DrSpratticus

HT @DanLinMD for noticing this… pic.twitter.com/6CW3ES4D81

Matt Cooperberg (@dr_coops) September 28, 2021

However, on Tuesday, the NCCN  reversed its guidance and reinstated its original recommendation that active surveillance is preferred. But there was a slight tweak made. The NCCN now recommends that "most" men with low-risk prostate cancer be offered active surveillance as the single "preferred" treatment option at the start of their cancer battle.

“Very glad to see this update! Great news and clarity for patients,” Dr. Cooperberg tweeted Tuesday afternoon.

New update @NCCN #prostatecancer: #activesurveillance once again “preferred” for most low risk disease. Very glad to see this update! Great news and clarity for patients.

Quick work by @EdwardSchaeffer @wandering_gu @urogeek et al.https://t.co/muCeTyATca pic.twitter.com/Ys8b25WGMJ

Matt Cooperberg (@dr_coops) November 30, 2021

Big news! NCCN guidelines updated again- active surveillance is "preferred for most patients" with low risk #prostatecancer and life expectancy of >=10y. Full version 2.2022 available online with free login: https://t.co/6G5Ya5VEPK https://t.co/J6PFcl1B8G

Stacy Loeb, MD (@LoebStacy) November 30, 2021

What is Active Surveillance for Prostate Cancer?

If you’re unfamiliar, you may be wondering what active surveillance is.

What is Active Surveillance?

Active surveillance is what’s known as a “watch-and-wait” approach for men with low-risk prostate cancer, meaning you have a small number of cancer cells found in your biopsy, a low PSA and a low-grade cancer. What’s a PSA score? PSA stands for prostate-specific antigen. It’s a blood test that screens for the cancer; it can also track a person's response to cancer treatment. PSA is a protein secreted by the prostate gland; a large amount of PSA in a person's body can indicate that cancer cells are growing. (But that isn't always the case, and some SurvivorNet experts disagree on when to use this test, if at all.)

With low-risk prostate cancer, a man’s risk of cancer getting out of the prostate and spreading to other parts of the body is "really, really low," explains Dr. Stephen Freedland, a urologist at Cedars-Sinai Medical Center, "so anything we do is going to be overtreatment." If you do opt for active surveillance, you'll regularly need a PSA test, rectal exam and high-quality imaging tests, which can identify small yet important changes.

Choosing active surveillance means you avoid the potential side effects of treatment, including sexual and urinary problems. But it’s important to remember that about 50% of men who opt for active surveillance will have changes within five years that require active treatment, Dr. James Brooks, chief of urologic oncology at Stanford Medicine, tells SurvivorNet.

The Benefits of Active Surveillance

When is Active Surveillance Not Enough?

Active surveillance is typically enough for men with low-risk prostate cancer. However, if you’ve been diagnosed with moderate-risk cancer, it can be a slippery slope, some SurvivorNet experts say.

When the prostate cancer is considered at a moderate risk, many men choose to begin active treatment.

How do you know what risk level your cancer is? That’s determined by something called the Gleason score. The higher your score, the most aggressive your cancer. The Gleason score is still considered the ultimate indicator of the potential for prostate cancer to grow and spread. (The lowest Gleason score is 6, which is a low-grade cancer. A medium-grade cancer, or moderate risk, is a Gleason score of 7 and a high-grade cancer is a Gleason 8, 9 or 10.)

Active treatment involves surgery to remove the entire prostate, radiation or cryotherapy.

When is Active Surveillance Not Enough?

Contributing: SurvivorNet staff

Learn more about SurvivorNet's rigorous medical review process.