When Is Active Surveillance Safe for Men With Prostate Cancer?

Gerald Chodak, MD


August 10, 2018

Hello. I'm Dr Gerald Chodak for Medscape. Today's topic is active surveillance of low-risk prostate cancer. It's based on a roundtable discussion[1] that [was convened by The ASCO Post and] included three experts: Dr Brian Chapin, Dr Jonathan Epstein, and Dr Maha Hussain. The panel was presented with a series of questions and discussed their opinions.

This topic is particularly important to me because, back in 1993, I was coauthor on a paper[2] about conservative therapy for localized prostate cancer. The paper received heavy criticism at the time. Now, some 25 years later, a growing number of experts are arguing that active surveillance, as a form of conservative therapy, should become the standard of care for men with low-risk disease.

Following are some of the topics the panel discussed. First, should a Gleason score of 3+3 [or Gleason 6] no longer be called prostate cancer? All three panelists felt that would be a bad idea. Gleason 3+3 has parameters that are associated with cancer, and although there may be a low potential for malignancy, no longer calling it cancer would provide misleading information.

Second, they talked about the criteria for selecting men for active surveillance. A growing number of people around the world have suggested that a minimum of criteria should include a prostate-specific antigen (PSA) less than 10 ng/mL, a Gleason score of 3+3, and either nonpalpable or minimally palpable disease. Both Dr Epstein and Dr Hussain said that we should be more restrictive in selecting men. They want to include the criteria of a PSA density of less than 0.15 ng/mL/cc and no more than three cores showing cancer, with none of them showing more than 50% cancer in any one biopsy. But that is not the standard from most centers around the world.[3]

Next, they talked about the problem of patient acceptance, and clearly this is a problem. Telling a man he has cancer and not offering definitive therapy is difficult for many men to accept. Those who are dealing with quality-of-life issues such as preserving sexual function and urinary control may have an easier time of it. But, clearly, work is needed to help men deal with the idea that they have cancer but they are not going to receive immediate therapy.

Last, they touched on the idea of using genetic testing to help select men [for active surveillance]. All three panelists acknowledged that the currently available tests are simply not good enough to help make definitive decisions about whether a man is a good candidate.

Some Important Questions Were Not Addressed

Unfortunately, the questions that were not addressed are equally important. They did not talk about whether a confirmatory biopsy should be performed before a man goes on active surveillance. Why do that? Because we know that many biopsies may miss areas of cancer that could harbor higher-grade disease.

Another very important issue is the role of periodic biopsies as part of the follow-up and management. The management of active surveillance is undergoing an evolution, and clearly one of the problems many men face is the idea that they will need periodic or repeat biopsies. Are [periodic biopsies necessary] and if so, how often? And if you're going to perform biopsies, [should we] routinely use MRI or is ultrasound good enough? Around the world, MRI is becoming more the norm [with] prostate biopsies because it allows men to avoid a biopsy if no lesion is found.

Another important question is whether patients with Gleason 3+4 [or Gleason 7] cancer should undergo active surveillance. We know that these men have a greater risk that the disease will progress. Nevertheless, many men who are diagnosed with 3+3 disease actually have 3+4 [disease] and we know that their risk for progression is still very low.

Finally, the panel did not discuss another critically important question: when to stop active surveillance. [When we see] a change in PSA on sequential tests? [When we see] changes in the grade or amount of cancer on a follow-up biopsy? What about the rectal exam changes that also may [signal] a worsening of the disease?

For now, we are left with helpful information, but also with the need for much more information about how to manage and how to select men for active surveillance. Hopefully, that will be forthcoming. I look forward to your comments. Thank you.


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