The Science Behind Active Surveillance
If every eligible candidate in North America and Europe pursued active surveillance, close to 300,000 men could be spared from unnecessary surgery and radiation every year. To date, the published literature on surveillance includes numerous prospective studies. These studies, which evaluate men who were mostly Gleason 3+3=6, fail to identify any increased risk of prostate cancer mortality.
Active Surveillance Technique
The way men on surveillance are managed is evolving rapidly. Historically, after the initial diagnosis of Gleason 6, a PSA blood test is performed every three months for the first two years, and then every six months thereafter. Another random biopsy is recommended within three to twelve months after the initial diagnostic biopsy and every two to three years thereafter until the patient reaches age 80 or has a life expectancy under five years because of other serious medical issues. Newer thinking relies less on random biopsy and more on MRI (Chapter 4) In a MRI-based protocol men undergo annual MRI at a center of excellence. Each year’s newly obtained images are compared to the previous year looking for growth or change in pre-existing lesions or the development of any new lesions. If any such changes occur, targeted biopsies are obtained from the specific area of concern.
PSA Monitoring on Active Surveillance
Experience has shown that PSA cannot be relied upon to make final decisions about treatment in men on active surveillance. This represents a shi ft in policy from earlier practice. Until MRI became available, men on surveillance with rapidly rising PSA levels (with a doubling time under three years) were usually offered treatment. One multi-institutional surveillance registry reported that 20 percent of the men participating in the study were treated because their PSA doubling time was less than three years. Another report from a study of over 1,000 men, describes the cases of five men dying of metastatic prostate cancer, all five of whom had a PSA-doubling time under two years. The main limitation of using the rate of PSA elevation to guide therapy is the lack of specificity. Vickers, in an overview of every large active surveillance study (each study had a minimum of 200 patients), concluded that changes in PSA had no independent predictive value. In another study, traditional PSA “triggers” (doubling time less than three years, or PSA rising at a rate of more than two points per year) occurred in 50 percent of stable untreated patients, none of whom went on to develop progressive cancer, require treatment, or die of prostate cancer. These studies show that great care needs to be exercised when interpreting the significance of a rise in PSA, so that men with moderate changes don’t overreact and seek unnecessary aggressive treatment. Active surveillance, with close monitoring and delayed intervention based on risk reclassification over time, is an appealing approach for Sky patients, and a welcome antidote for the 100,000 men in the United States diagnosed every year with Gleason grade 6, many of whom, sadly to this day, are still being encouraged to undergo surgery or radiation by their doctors.
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Laurence Klotz, MD is the past Chief of Urology at Sunnybrook Health Sciences Centre and Professor of Surgery at the University of Toronto. He is also Chairman of the World Uro-Oncology Federation and a past president of the Urological Research Society and the Canadian Urological Association. Dr. Klotz was the Founding Editor-in-Chief of both the Canadian Journal of Urology and the Canadian Urology Association Journal (CUAJ), and is now Editor Emeritus of the CUAJ. He was the founder and is chairman of the Canadian Urology Research Consortium. Dr. Klotz obtained his medical degree from the University of Toronto and completed his residency at the University of Toronto Gallie Program in Surgery. Dr. Klotz continued his postgraduate studies with a special fellowship at Memorial Sloan Kettering Cancer Centre in New York, in uro-oncology and tumour biology. Dr. Klotz is a widely published uro-oncologist with over 300 publications and 4 books. His main research interest has been prostate cancer. He serves on the boards of many medical/scientific organizations and journals, including the SUO[1] , Prostate Cancer Canada, the journals Prostate Cancer and Prostatic Diseases, Brazilian Journal of Urology, Italian Journal of Urology, and World Journal of Urology. He was recently awarded the Queen’s Jubilee Medal for meritorious public service.