Satyendra Persaud MBBS DM (Urol) FCCS Registrar, Department of Urology, San Fernando General Hospital, Trinidad and Tobago
Last session, I outlined several options for the management of localized disease – that is, when the cancer is only in the prostate and nowhere else. To recap, these were:
Active surveillance – the cancer is observed closely and treated with curative intent only if necessary.
Radical prostatectomy – the prostate is surgically removed.
External beam radiotherapy – a powerful machine is used to deliver radiation beams to the prostate, usually utilizing a CAT scanner to ensure the beam is aimed only at the prostate.
Brachytherapy – this uses radiation as well but the radiation is delivered in the form of tiny seeds which are surgically implanted in the prostate.
Who is suitable for active surveillance?
There is still a lot we don’t know about prostate cancer. We do know that not all cancers will progress quickly and a quite a few will never pose a danger to the man’s life. Active surveillance is a strategy to avoid over treating these indolent, low risk cancers. Low risk and very low risk cancers are identified based on the digital rectal exam, the PSA and on the prostate biopsy – for this, you should have a well done, ultrasound guided prostate biopsy. If only a few cores of your biopsy have cancer, the cancer doesn’t occupy much of each of the cores and it is a well differentiated cancer, then you may be suitable for active surveillance.
How will I be followed up?
The patient is followed closely and the PSA is checked often, usually every 3 months. Because prostate biopsy is not perfect, we recognise that there will be cases in which the patient harbours more aggressive disease than was appreciated on the original biopsy. It is important to identify and treat these patients early as they are at high risk of progression of their disease if left alone. For this reason, the urologist will advise on repeat biopsy usually at an interval of 12-18 months. In fact, some centres even recommend rebiopsy as early as 3 months. If aggressive disease is found on rebiopsy then the patient is offered curative treatment.
Why would I be offered treatment?
There are several reasons why the urologist would advise that the patient stop observation:
The patient requests curative treatment.
The patients PSA starts to rise or his digital rectal examination reveals evidence of progression.
As mentioned above, the repeat biopsy shows evidence of more aggressive disease.
What are the outcomes for active surveillance?
Active surveillance has been around for quite a few years now and data are available from large centres- Johns Hopkins, University of Miami and University of Toronto to name a few. These studies have shown that only one out of every 3 men will fail observation and require treatment. It has also been shown that active surveillance is safe as survival in most of these series approaches 100%. This shows that survival is not compromised with close observation – once the higher risk cancers are identified early and treated, outcomes are good.
Conclusion
In summary, active surveillance is a very safe option for men with low risk disease. The patient is watched very closely and is offered curative treatment at the earliest evidence of disease progression. In this way we can avoid unnecessary treatment in a large percentage of men.
As usual I am happy to answer any questions via email – satyendrapersaud@yahoo.com
