PROSTATE CANCEr 

Active Surveillance

In order to maintain a patient’s quality of life (and avoid over-treating patients), some patients with early-stage disease have been placed on active surveillance. Under active surveillance, patients are not treated immediately. Instead, they are monitored closely, and with repeat biopsies, the volume and aggressiveness of their prostate cancer are monitored. Prostate cancer treatment is then offered when a patient’s volume increases or if the aggressiveness of the prostate cancer worsens (or if the patient no longer wants to remain on active surveillance).

At that time, either surgery or radiation therapy is provided to the entire prostate gland with the potential side effects as listed above (impotence, loss of urinary control, change in ejaculation, etc.).

Treatment is then offered when a patient’s cancer volume increases or its aggressiveness worsens (or if the patient no longer wants to remain on active surveillance). At that time, either surgery or radiation therapy is provided to the entire prostate gland with the potential side effects as listed above (impotence, loss of urinary control, change in ejaculation, etc.).

One of the shortcomings with an active surveillance approach to prostate preservation is that because patients are not being treated promptly and treatment is delayed until there is the further progression of their cancer (either in terms of volume or aggressiveness), it’s possible that they will ultimately develop more volume of disease.

Clearly, a prostate preservation middle ground has to be available for patients with prostate cancer. On one hand, we do not want to over-treat patients, but we do not want to delay treatment to the point that patients have lost the chance of being cured, either. Comprehensive Urology of LA utilizes various prostate preservation techniques depending on each patient’s unique disease.

How does Active Surveillance work?  

Active surveillance as a viable treatment option has gained traction in recent years once it became obvious that aggressive treatment in low-risk cases creates more harm than good.

Men with a small, early-stage tumor or a low Gleason score most likely should not undergo immediate radical treatment. On the other hand, taking a wait-and-see attitude toward a metastasized tumor might not be the most effective plan.

Active surveillance should not be considered a form of “no treatment.” Instead of direct manipulation of the tumor or affected gland, it is a proactive monitoring of the tumor through regular exams, including DREs (digital rectal exams) or PSA testing (prostate-specific antigens).

It could also be considered deferred treatment because you do undergo treatment once it becomes really necessary, thus avoiding the treatment side effects as long as safely possible. There is much documentation of men with the low-risk type of the disease readily surviving 10-15 years after diagnosis with simple, yet regular surveillance. The rate of metastasis or death is remarkably low, indicating that in these cases, immediate or aggressive treatment would not have improved the outcome; in fact, it could be argued that such types of treatment would have reduced their quality of life due to the unwanted side effects which can be significant.

The key to success with active surveillance is regular monitoring and undergoing prostate cancer treatment once the tumor becomes more aggressive.

What happens to the Cancer while on surveillance?
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If a patient has been diagnosed with localized or early stage cancer, active surveillance is a viable method of treatment; instead of being immediately treated, the tumor is monitored closely, specifically its growth and aggressiveness.

More aggressive prostate cancer treatment is implemented only when the tumor enlarges, the aggression increases or the patient decides to undergo such treatment.

The tumor remains in your body. Research suggests that in the decade after the original diagnosis for men undergoing active surveillance more than half don’t warrant treatment during that period.

 The truth is that it’s not for everyone. It takes commitment and a willingness to follow the recommended active surveillance plan. 

Though customized to meet your goals and treat your specific case, a plan is based on the following:
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  • PSA level every 3-6 months
  • Repeat prostate biopsy within 18 months of diagnosis (then as necessary afterward)
  • DRE (rectal exam) at 6 months or 1 year

When is Active Surveillance Recommended?

 

Since many patients are treated more aggressively for cancer than is necessary to survive, a common question about treatment is when are conditions right for active surveillance?

Below are general guidelines that are considered ideal:

  • The tumor is considered to be low risk
  • PSA level less than 10
  • Gleason score 6 or less (some consider select 7 cases for this as well)
  • The tumor is small and confined to the prostate (ideally less than 3 biopsied cores involved)

Another situation where active surveillance is also a useful approach for older men with a limited life expectancy, especially if they are also dealing with other ailments and chronic health issues. In such cases, immediate therapy might cause more complications with no meaningful benefit.

ACTIVE SURVEILLANCE

FAQ

What are the downsides of Active Surveillance?

One of the shortcomings with an active surveillance approach is that because patients are not being treated promptly and treatment is delayed until there is the further progression of their cancer (either in terms of volume or aggressiveness), it’s possible that they will ultimately develop more volume of disease. If this happens, a patient’s chance of being cured is decreased, and their prostate cancer can actually spread outside the prostate where it is no longer curable. Because of the delay in treatment, the outcomes for a number of patients on active surveillance will be less than optimal.

Clearly, a middle ground has to be available for patients with prostate cancer. On one hand, we do not want to over-treat patients with prostate cancer, but we do not want to delay treatment to the point that patients have lost the chance of being cured, either.

Prostate cancer is among the slowest growing of all cancers; thus, a diagnosis does not automatically mean reduced life expectancy. Many treatments are available at Comprehensive Urology of Los Angeles, including whole gland procedures and focal treatments. The former includes aggressive therapies such as surgery or radiation while the latter group comprises less invasive procedures such as HIFU or MRI-fusion HIFU.

In many cases, aggressive treatment is unnecessary and even harmful. While they can certainly bring good results, they also carry risks such as increased chances of ED or urinary dysfunction. This might not work for men with the following:

  • Early stage prostate cancer
  • A small or localized tumor
  • A non-aggressive tumor
  • A low Gleason score
What factors are considered when devising a plan?

If you have been diagnosed with prostate cancer, the following factors should be taken into account in order to create the proper treatment plan:

  • Tumor size
  • Tumor stage
  • Aggressiveness of tumor
  • The degree of spread (metastasis)
  • Gleason score (tumor grade)
  • PSA level
  • Patient age
  • Patient’s will to survive
  • The overall health of the patient
  • Patient concerns
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