Active Surveillance

BY MARK SCHOLZ,MD

A Cancer that Can be Watched

If someone tells you your cancer can be watched instead of treated, your initial reaction might be that they have no idea what they are talking about.  Outside of the medical world, all cancers are believed to be life threatening with a need for immediate treatment. Surprisingly, this is not necessarily the case with prostate cancer.  Carefully selected types of prostate cancer can be safely monitored without immediate treatment.  This is fortunate because surgery and radiation, even in the most skillful hands, frequently cause irreversible sexual and urinary side effects such as impotence and incontinence.

Why Can You Safely Watch Cancer?

Prostate cancer is radically different from other types of cancer. Let’s use colon cancer as an example of “cancers-in-general.” With colon cancer, one in three patients dies. With prostate cancer, the mortality rate is one in twelve.¹ Average longevity with colon cancer is one year. For prostate cancer it’s 13 years!²  Prostate cancer is so dramatically different, that for carefully selected men the best course of action is active surveillance.

Active Surveillance is Attractive Because Treatment is Risky

The side effects of surgery and radiation can be devastating. Sadly, the general public rarely hears about these problems because patients are too embarrassed to discuss the intimate aspects of their lives. In a study of 475 men who had surgery, less than 20% of men described their sexual function as returning to normal.¹ In another study of 785 men, less than 20% of men who had surgery and less than 50% of the men who had radioactive seeds, described their sexual function as returning to normal.²    

Distinguishing “Good” from “Bad” Prostate Cancer

Since mortality is uncommon, the most important question is, “Can doctors reliably spot the less-common, aggressive-type of prostate cancer and treat it before it spreads?” The answer is, “Absolutely, yes!” Bad types of prostate cancer are easy to identify using modern scanning, PSA testing, and accurate cancer grading.

What is The Active Surveillance Plan?

Men on active surveillance generally undergo PSA testing three or four times a year and have a multiparametric MRI or a Color Doppler ultrasound once a year. If a new lesion appears, or if a pre-existing lesion grows, a targeted biopsy is recommended to see if the Gleason grade has changed. 

Why Do Some Doctors Resist Active Surveillance?

Watching prostate cancer is a relatively new idea. Unless doctors are aware of the latest research, watching cancer may seem counter-intuitive. Ill-informed physicians fear malpractice suits, thinking that the cancer might unexpectedly spread. In addition, urologists, the type of doctors who typically treat prostate cancer, are rigorously trained to do surgery—­­­ they naturally tend to be more comfortable operating than watching.

Why Do Some Patients Lean Toward Treatment?

Frightened patients want immediate closure. “Cutting the cancer out” sounds like a wonderful plan, but most patients don’t fully understand how frequently irreversible side effects occur. In addition, patients are influenced toward treatment by anxious family members who assume all prostate cancer is deadly.

Final Thoughts

The popularity of active surveillance continues to increase as doctors learn of its advantages. Patients are generally thrilled when they hear that surgery or radiation can be safely avoided and that unpleasant random surveillance biopsies are being replaced with modern MRI scans. Each day, more and more men are embracing the active surveillance lifestyle.

References

1. John Gore, Journal of the National Cancer Institute, Vol. 101, P. 888, June 2009.

2. John Malcolm, Journal of Urology, Vol. 183, P. 1822, May 2010.