Sunnybrook Health Sciences Centre’s Laurence Klotz, MD, speaks with PCRI about management of low-risk prostate cancer with Active Surveillance. 

What is active surveillance, and how does it compare with other methods of treating prostate cancer?

The concept of conservative management for prostate cancer is not new. In fact, in Scandinavia and England in the 70s, basically no one was treated until they had metastatic disease. And the idea was that treatment....

It seems we have a national passion for prostate biopsies. A million men are biopsied every year. Two hundred thousand of them will be diagnosed with prostate cancer and about half of these with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, more than half of these men with Low-Risk will undergo prompt, radical treatment.  Sadly, irrational fears rooted in the electrifying word “cancer” drive most men into taking immediate action.

Why Screen for Prostate Cancer?

Screening finds earlier stage cancers, allows for simpler treatments with fewer side effects, and saves lives. For example, in 1985, prior to PSA screening, the prostate cancer five-year survival rate was 69% compared to 99% in 2006. It’s unclear whether this dramatic survival increase is entirely due to PSA screening. Other factors, such as improved therapy have also contributed.

New prostate cancer drugs come to market quite rarely because the studies mandated by the FDA cost hundreds of millions of dollars. The FDA requires these studies to randomly allocate men into two comparison groups. One group receives the new medicine being tested. The other group gets an ineffective fake, called a placebo. Assuming the study is performed in an acceptable manner, the FDA will approve a new drug for commercial use, only if the men who are receiving the new medicine outlive those treated with the placebo by a specified margin without excessive toxicity.

Studies designed to evaluate the effectiveness of surgery for prostate cancer take a long time to perform because prostate cancer grows much slower than other cancers.  Since it is primarily in older men, mortality from unrelated causes—other cancers, heart disease and simply old age—frequently occurs before the prostate cancer progresses enough to impair health. 

The majority of radical treatment decisions are made on the basis and results of PSA testing. PSA or Prostate-Specific Antigen, is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. Due to the dangers of overtreatment some experts have proposed forgoing PSAtesting altogether. However, this attitude is like throwing the baby out with the bathwater, since early diagnosis and treatment of high-grade prostate cancer unquestionably improves survival and quality of life.  

“No More Unnecessary Biopsies . . . ” The first four words of the sub-title of our book, Invasion of the Prostate Snatchers,” are a clear statement of our objective. I am no fan of biopsies. At the same time I know that a biopsy is an essential diagnostic tool when appropriately used. The problem is that too many doctors schedule an immediate biopsy if there is only a slight rise in PSA, when it would be more appropriate to explore less invasive diagnostic methods first.