Wednesday, October 8, 2014

Active surveillance for prostate cancer: What is it and is it right for me?


PART TWO


Click here to read PART ONE of Active surveillance for prostate cancer: What is it and is it right for me?



What is the protocol for follow-up?

Similar to entry criteria, the optimal protocol for monitoring patients on active surveillance is a point of discussion and considerable variation among urologists. The majority of surveillance programs use serial DRE (digital rectal examination), PSA (prostate specific antigen), and prostate biopsy, with some programs more recently adopting MRI (of the prostate) as well. The frequency with which men should undergo biopsy is the subject of much debate and may be as often as every year. Our program has traditionally recommended yearly biopsy, as well as DRE and PSA every six months. With the incorporation of MRI into the follow-up protocol, however, we hope to decrease the frequency of required biopsies without compromising our high level of monitoring. The basic monitoring protocol based on risk factors is listed below.


Test
Interval
DRE, PSA
6-12 months
12-14 core biopsy

Annual
1)    Patient preference
2)    Not very low risk and >10 year life expectancy
3)    Very low risk and PSA >10 ng/ml


Biennial
1)    Very low risk and no MRI lesions with score 4,5 if prior targeted biopsies of score 3 lesions are negative



Not indicated
1)    Age >75 years and MRI shows no lesions with score ≥3

MRI
Biennial with targeted biopsy of any lesions score 3,4,5

 

What leads to recommending treatment?

Treatment is generally recommended when men no longer meet the LR or VLR criteria for entry, an event termed "reclassification." This is most frequently a result of adverse pathological findings on surveillance biopsy (i.e. increased volume of cancer or Gleason score (greater disorganization of cells)). Although we do not, some institutions recommend treatment based on an increase in PSA values. Over a ten year period, approximately one third of men will undergo a treatment. The majority of those men, approximately 70%, elected treatment due to an increased volume of cancer or Gleason score > 6 – indicating the presence of more aggressive cancer.[1]


Criteria for curative intervention

Patient preference


Reclassification of risk
  • Very low à low risk, with life expectancy >20 years


Gleason
  • Any pattern 4 and life expectancy >10 years
  • ≥4+3 and life expectancy >5 years


PSA
  • 10-20 ng/ml and not very low risk
  • >20 ng/ml



Is active surveillance safe? 

Surveillance is accepted as a management strategy under the presumption that close monitoring allows us to identify and treat cancers which are later found to be higher-risk without missing the window of opportunity for cure. There have been no randomized-controlled trials demonstrating this as fact, though initial results from several institutions have been promising. Reviews of the published literature demonstrate prostate cancer as a cause of death in less than 1% of patients who have participated in active surveillance.[2] It is crucial, however, to understand that the length of follow-up in most cohorts is not yet sufficient to rule out additional prostate cancer-related deaths in the coming years. The true rate of death due to prostate cancer is likely higher than 1%, but to what extent will not be known until more patients have been followed for a greater length of time.

 

Is active surveillance right for me?

Like most health-related decisions, deciding for or against active surveillance is a personal decision that should consider many factors. As discussed, the aim of active surveillance is to avoid unnecessary treatment of low-risk cancers and the negative impacts treatment may have on quality of life. Unfortunately, this comes at the risk of failing to treat a cancer deemed low-risk while it remains curable, allowing the window of opportunity for cure to pass.
  • When considering active surveillance, there are a number of important questions to ask.
  • How much do you value the peace of mind associated with early treatment, knowing that treatment may not have been necessary at all?
  • How much impact would the possible side effects of treatment such as loss of potency and continence have on your quality of life?
  • Are you comfortable with the idea of monitoring your cancer, knowing there is a small risk it will prove to be harmful in the future?
  • Are you willing to follow-up with your doctor for exams and testing every 6 to 12 months?

 

Active surveillance appears to be a safe and reasonable option for appropriately selected men. Deciding whether surveillance is right for you remains difficult, but discussing your options with your family and physician in the context of your personal values should help you to make this important decision with confidence.

 

The Blog was written by Jeffrey Tosoian, MD (@UroDocJT). Dr. Tosoian is a PGY3 (Post-Graduate Year 3) urology resident at the Brady Urological Institute at Johns Hopkins.








REFERENCES
[1] Tosoian JJ, Trock BJ, Landis P, Feng Z, Epstein JI, Partin AW, Walsh PC, Carter HB. Active surveillance program for prostate cancer: an update of the Johns Hopkins experience. J Clin Oncol. 2011 Jun 1;29(16):2185-90. doi: 10.1200/JCO.2010.32.8112. Epub 2011 Apr 4. http://jco.ascopubs.org/content/29/16/2185.long
[2] Dall'Era MA, Albertsen PC, Bangma C, Carroll PR, Carter HB, Cooperberg MR, Freedland SJ, Klotz LH, Parker C, Soloway MS. Active surveillance for prostate cancer: a systematic review of the literature. Eur Urol. 2012 Dec;62(6):976-83. doi: 10.1016/j.eururo.2012.05.072. Epub 2012 Jun 7. Review.

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