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An option for low-risk prostate cancer

For some men, the smartest move after diagnosis may be to delay treatment and carefully watch the progression of the cancer.

After a prostate biopsy confirms cancer, the next step might seem obvious: get treatment as soon as possible, either by removing the prostate gland entirely (radical prostatectomy) or zapping it with radiation. But immediate treatment is not the only option or necessarily the best one. Treatment itself can cause more harm in the long run than the cancer. Some men with early low-risk prostate cancers can choose to hold off on the decision to treat until the disease presents a greater threat. Then the cancer can still be treated effectively. The approach is called active surveillance with delayed intention to treat.

“With active surveillance, we continue to monitor the cancer very closely to get a grasp on its behavior before committing to treatment,” says Dr. Marc Garnick, a prostate cancer specialist at Harvard Medical School and Beth Israel Deaconess Medical Center. “For many men, active surveillance makes more sense than immediate treatment. It allows them to avoid the potential harms and uncertain benefits of treating a low-risk cancer.”

Reasons to defer treatment

For a man in his 70s or 80s with a low-risk cancer, it may take more than a decade for the tumor to cause symptoms. In the meantime, treating the cancer with radiation or surgery comes with significant risk of bothersome and potentially permanent side effects, including erectile dysfunction and urinary incontinence.

By choosing active surveillance, a man can avoid the risks of treating a cancer that is unlikely to cause him serious harm within his expected lifespan. He may end up dying with the cancer but not from it.

However, certain men at higher risk should probably consider immediate treatment:

  • Men 50 to 60 years old who have early-stage cancer that looks potentially aggressive, based on the pathology report from the biopsy, and who have a family history of prostate cancer.

  • Men who, despite evidence that the cancer is likely to be slow-growing and does not present an immediate threat, are still very worried that the cancer could spread.

How surveillance works

Active surveillance is frequently and mistakenly referred to as “watchful waiting.” But there are important differences between the two strategies. The intention of watchful waiting is to spare older adults the harms of treatments that are unlikely to improve their well-being or extend their lives. But watchful waiting does not include intensive follow-up to determine whether a cancer is growing or changing in some way—usually by obtaining repeat prostate biopsies. Instead, the doctor offers treatment only when symptoms arise.

“Men offered watchful waiting are usually elderly and have other health problems,” Dr. Garnick says. “If they were younger, they would probably be offered treatment. But because of the time it will take for the cancer to cause symptoms and the competing causes of death, they choose not to be treated while they have very few or no symptoms from their cancer.”

In contrast, active surveillance is not a passive process. “We meticulously follow the progression of the cancer,” Dr. Garnick says. “In the absence of symptoms, if that cancer is getting worse by any one of a variety of criteria, then treatment is generally recommended. However, we are still uncertain about the benefits that treatments provide, making the decision to get treated that much more difficult.”

The Gleason score: How fast is it growing?

The Gleason score is a tool to rank prostate cancer based on how likely it is to grow and spread. Pathologists examine the two most common type of cancerous cells collected during a biopsy and assign each a grade from 1 to 5 based on their appearance. Combining the two grades—4+3, for example—yields a Gleason score from 2 to 10. The lowest Gleason scores indicate slow-growing cancers that are unlikely to break out of the prostate gland and spread (metastasize).

Who could consider active surveillance?

According to the current expert consensus, men who meet certain criteria may consider active surveillance. The details should be discussed with a doctor, but in general active surveillance is for men with PSA scores and/or biopsy findings that indicate a slow-growing, early stage cancer. These are the technical criteria:

  • PSA score less than 10

  • a Gleason score less than 7

  • tumor at stage T2a or lower
    (T1 is the least advanced tumor type; T3 is the most advanced.)

  • no more than 50% of a biopsy sample showing cancer

  • a slow PSA doubling time, usually greater than three years.

Age is a critical factor for men considering active surveillance. “Out of 100 men at 75 years old with low-risk prostate cancer, 70% will never have problems with it in their lifetimes,” Dr. Garnick says. The other 30% may eventually develop symptoms of the cancer. But their survival without any treatment could be eight to 23 years after diagnosis, depending on the aggressiveness of the tumor.

Another important consideration is other health conditions the man may already have when he is diagnosed with cancer—heart disease, for example. “The competing causes of death need to be weighed in decision making,” Dr. Garnick says.

How much surveillance?

Expert recommendations vary on the level of monitoring a man should expect under active surveillance. But this strategy is typical:

PSA and DRE: After an initial biopsy confirms cancer, the man will be advised to have repeat PSA testing and a digital rectal exam (DRE) every three or four months. During a DRE, the doctor inserts a lubricated, gloved finger into the rectum to feel for irregularities in the prostate.

Biopsy: Active surveillance will require follow-up biopsy every 12 to 18 months or longer. Some doctors may advise follow-ups only every three years if the first round is negative. “The decision about how frequently to biopsy is a shared decision,” Dr. Garnick says. “It’s especially important to consider the side effects the man had from past biopsies.”

When to consider treatment?

In active surveillance, your physician will be looking for signs that the cancer is advancing or has become more aggressive. Possible trouble signs are

  • a sharp rise in your follow-up PSA test results (although this could be from a cause unrelated to cancer, such as an infection, and would require confirmation with a biopsy)

  • a known tumor that now feels larger based on a DRE, or a change in the MRI scan showing that the tumor has enlarged.

  • an increase in the number of biopsy samples containing cancerous cells, or an increase in the actual amount of cancer in each biopsy specimen.

  • a change to a higher number in the Gleason score as determined by a follow-up biopsy.

Weighing the benefits of treatment

Men who choose surgical treatment instead of active surveillance should be aware that treatment can cause harm, including erectile dysfunction and incontinence, which can erode quality of life.

In addition, treatment is by no means a guarantee of cure. Between 15% and 30% of men will have a relapse, and will die from prostate cancer if another disease does not cause death first. But for the average man who has a relapse, death will not occur until about 17 years after the treatment.

“Men often think that if they have no immediate problems during surgery and the post-operative period, then they’re home free,” Dr. Garnick says. “However, every treatment can cause lasting harm, and no treatment is guaranteed to be curative.”

PIVOT: Important new findings on surgery vs. watchful waiting

In men diagnosed with prostate cancer, which choice better reduces the risk of death from cancer: immediate surgery or waiting to treat until symptoms arise—a strategy known as watchful waiting?

Overall, neither approach is superior, according to the Prostate Cancer Intervention Versus Observation Trial (PIVOT). The study included 731 men with cancer confined to their prostate glands. In half the men, the cancer was detected with PSA screening and was still too small to be felt during an exam.

Half of the men were chosen at random to have their prostates removed. The others were monitored and offered surgery if they developed symptoms of advancing prostate cancer. Men in both groups were seen every six months until death.

Survival after diagnosis differed very little between the men who had surgery and those who were offered observation only: 13 years vs. 12.4 years. Over all, there was no difference in the rates of dying from prostate cancer between the groups. But a small percentage of men with higher-risk cancers—as indicated by PSA scores over 10—seemed to benefit more from surgery. Over a 10-year period, for every eight of these higher-risk men who had their prostates removed, one of them survived longer compared with the men in the watchful waiting group.

PIVOT suggests that men with low-risk cancers should not expect a dramatically greater benefit from immediate surgery. For men with higher-risk cancers, there is also an important message, says Dr. Michael Barry, a clinical professor of medicine at Harvard Medical School and a researcher on PIVOT starting in 1994. “We’ve always thought that cancers need to be detected as early as possible,” Dr. Barry says. “But PIVOT suggests they need to be diagnosed as early as necessary. For many men, the necessary point comes at higher PSA levels.”

Posted by: Dr.Health

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