A diagnosis of prostate cancer can raise a lot of questions. You might wonder if you'll start radiation right away, or if surgery or chemotherapy is in your future. Many patients also worry about how cancer treatment might impact their quality of life.
You may be surprised if your prostate cancer specialist recommends not treating the cancer immediately. This approach is clinically referred to as active surveillance, and it's now considered a good way to manage low-risk prostate cancer.
Dr. Brian Miles, a urologist at Houston Methodist specializing in prostate cancer surgery, shares why this option can be beneficial for patients with newly diagnosed prostate cancer and who might be a good candidate.
Is the prostate cancer slow growing?
As part of your diagnosis, your prostate cancer specialist will perform a series of tests to determine the grade and stage of the cancer. If it's determined to be low grade, active surveillance may be recommended instead of treatments like surgery and radiation therapy.
"If we confirm the cancer is localized to the prostate, we consider the fact that prostate cancer can often be indolent," Dr. Miles explains. "This means the cancer cells can be present for years without spreading or causing symptoms."
This is where active surveillance comes into play. "It's the clinical protocol for managing prostate cancer when it has a low risk for developing into a more serious tumor," explains Dr. Miles.
Why choose active surveillance?
Extensive research shows that most men with low-grade prostate cancer do not need immediate treatment. Instead, your care team measures cancer markers at regular intervals to monitor for any changes.
"People often think, 'Wait a minute, I have cancer — shouldn't we treat it?" Dr. Miles says. "Active surveillance doesn't mean 'go home, you're good, don't worry about it.' It means we're watching closely to see if the cancerous cells are changing over time."
The primary goal of active surveillance is to avoid invasive treatment for patients at low risk of developing advanced prostate cancer.
"While prostate cancer is highly treatable, the interventions can have a significant impact on quality of life," explains Dr. Miles. "Side effects of treatment can include bladder or bowel problems and erectile dysfunction."
The clinical guidelines for active surveillance include regular follow-ups and testing, including:
- Prostate-specific antigen (PSA) test every six months to trend check for elevated levels
- Physical exam every year
- MRI scan every year
- Periodic biopsies, to be sure the cancer has not grown or become more aggressive
- Genomic testing of the cancer in the biopsy specimen, to be sure it will not actually behave like a more aggressive cancer
"We likely won't biopsy every year forever," Dr. Miles adds. "If your prostate cancer doesn't change, we can start lengthening the time between biopsies, and then eventually we may not biopsy at all if your other tests remain stable."
(Related: Prostate Cancer Screening: 5 Things Every Guy Needs to Know)
Who is a good candidate for active surveillance?
Active surveillance is typically recommended for patients who score low on the Gleason scoring system. Your care team assigns this number by analyzing the structure and patterns of cancer cells within your prostate gland. A score of 1 means the cells are nearly normal, while a 5 indicates that only abnormal cells are present.
Because cancer cells can differ in different areas, diagnoses typically include two scores — the most common grade and the next most common grade. The numbers are noted individually, then added together.
- A low-grade tumor has a Gleason score of 3+3=6 or less, and at times low volume 3+4
- A high-grade tumor has a Gleason score of 4+3=7 or higher.
(Related: Prostate Cancer Grading & Staging: What the Numbers Mean)
"Men who are perfect candidates for active surveillance are those with Gleason 3+3 disease," Dr. Miles says.
Your care team will also consider the volume of cancer cells. This measurement determines how many of the core samples from your biopsy are positive for cancer. "We may also include men with 3+4 disease, if the volume is low," adds Dr. Miles.
What happens if the cancer changes during active surveillance?
For starters, Dr. Miles emphasizes that if surveillance shows concerning changes, cancer treatment can begin at any time without worsening the prognosis. A cure is still highly probable.
"A recent research study showed that 10 years after diagnosis, nearly 50% of men who chose active surveillance showed no progression or needed no treatment," Dr. Miles says. "Less than 2% of study participants with 3+3=6 disease developed advanced cancer that spread, and less than 1% died of cancer."
His message is clear: "We don't miss a window of opportunity for a cure by watching you closely. This is a proactive approach that's proven to be very effective, and it's something I encourage every eligible patient to think about."
