Active surveillance for prostate cancer
Active surveillance for low risk and some medium risk prostate cancers is a very safe way of managing the disease
What is active surveillance for prostate cancer?
Active surveillance is process of monitoring low risk prostate cancer and in some cases, patients who have medium risk prostate cancer which is of a small amount that carries a low risk of progressing if left without any treatment.
What is the difference between watchful waiting and active surveillance?
In some patients who have other competing risks to their life expectancy, it would not make sense to offer any active treatment for the prostate cancer unless it was causing side-effects. In other words, something else will cause death earlier than we expect the prostate cancer to do so. In such patients, we generally advise a process called watchful waiting. Watchful waiting is different to active surveillance in that the intent when monitoring the cancer is not eventually cure the disease if it progresses (as it is with active surveillance), but to relieve any side-effects or deterioration in quality of life if the cancer progresses. Watchful waiting can be carried out in all risks of prostate cancer, as it is determined by the patient’s general health.
Why choose active surveillance rather than treating the cancer?
We know that prostate cancer, when it is contained in the prostate and has a low risk of progressing, is better suited to active surveillance rather than active treatment. Studies have shown that if you broadly carry out active surveillance and compare it to radical treatments such as surgery or radiotherapy, then over a 10 year period of follow-up there is little to no benefit in terms of patients surviving longer if they have treatment, rather than surveillance. The old adage that a man with prostate cancer ‘dies with it rather than from it’ counts in the majority of patients who have low risk prostate cancer or a small amount of medium risk prostate cancer.
For instance, on average, patients over the age of 50 have a one in three chance that there is a tiny amount of low risk cancer in the prostate, which they will not know about and they will not find out about because the disease does not change or grow or spread or cause any problems with their quality of life. Unfortunately, sometimes because we carry out a biopsy of the prostate, we can find these areas of low risk disease inadvertently, because needles can hit those areas and the pathologists then diagnosis it on the tissue slides that are taken. Whilst we have become much better at diagnosing high risk prostate cancer using MRI and targeted biopsies, there are some patients who have a suspicious MRI which require biopsy, but that suspicious area in the MRI is not necessarily caused by prostate cancer, but more often caused by inflammation or other changes in the prostate. As a result of those suspicious changes, needle biopsies are carried out and we can sometimes rather randomly and inadvertently find low risk areas of cancer which would otherwise have remained ‘dormant’ and not been noticed by the patients.
What is involved in active surveillance?
Active surveillance involves monitoring low and small amounts of medium risk prostate cancer with regular PSA blood tests. In the past, the disease used to also be monitored with regular biopsies, with some centers carrying out biopsies every one to two years. This was because people had very little confidence in the initial biopsy, which was a rather random test and carried out sampling of the prostate randomly without knowledge of where any tumor was present, if it was indeed present. As a result, patients with low risk disease on the traditional random transrectal (back passage) biopsy had a one in three chance and sometimes a one in two chance of having something more significant or life threatening, which the original biopsy missed. When active surveillance was developed about a decade ago, physicians wanted to make sure that nothing serious was being missed if a patient went on active surveillance. Therefore, they advised regular biopsies every one to two years. In the current era of MRI first and then MRI targeted biopsy, we know the error of missing important cancer when you have low risk cancer on your more accurate MRI and targeted biopsies is much lower. It isn’t zero, but it’s in the order of 5% to 10% and these areas tend to be quite small and still slow growing.
We also have some evidence that MRI used as an active surveillance tool, instead of repeated biopsies, is a good way of monitoring the disease and seeing the state of the prostate. As a result, active surveillance under my care is with regular PSA blood tests every four to six months. An MRI scan one year after diagnosis so that the MRI can be compared to the original diagnostic MRI that patients have had. Thereafter, we carry out an MRI every two or three years or more frequently if necessary, depending on what’s happening with the PSA blood tests. We normally expect the PSA to fluctuate a little but if the overall trend of the PSA blood tests is on the rise without any other cause, such as inflammation, prostatitis or infection of the prostate or urine, then an MRI would be brought forward. If that MRI showed a change in the prostate, such as an area that was proven to be tumor changing in intensity or in size, or if there is a new area that looks suspicious, then we carry out a further prostate biopsy using an accurate targeting approach and a transperineal route with needles going through the skin rather than through the back passage. This is much more accurate than a random biopsy that we used to do in the past and the transperineal approach reduces the risk of infection significantly.
Am I suitable for active surveillance?
When we are deciding on active surveillance, we look at the risk of disease and we also look at the individual patient. If patients have low risk disease, then generally, we will advise them to have active surveillance regardless of their age. This is because although there is a small chance of the disease progressing over time on active surveillance, this does occur over a number of years and therefore, a young patient can avoid treatment related side-effects such as urinary problems or erectile dysfunction and sexual problems for a number of years. So, even if treatment has to be carried out later, a patient gains a number of years of good quality of life without compromising subsequent life expectancy because studies have shown that in the small number of patients who subsequently need to have treatment, the window of opportunity for cure is not lost. This is providing the patient follows the active surveillance protocol carefully and advised by their urologist. We know from very good evidence that active surveillance done well with regular PSA measurements, MRI and biopsy if necessary, is a safe approach and can pick up a progression early and treatment can be instituted if necessary in the minority if needed at that point.
Someone with a small amount of medium risk disease which is scored as a Gleason 3+4=7 or what the new terminology calls an ISUP Grade Group 2 which has no more than 20% of the pattern four in the biopsies may also be suitable for active surveillance. Generally, the feeling is that this sort of disease does grow but it grows very slowly and therefore there is still an opportunity for a number of years of active surveillance in those patients who do not want to have immediate treatment.
The other factor we look at is whether the tumor on biopsy is visible on MRI. If the tumor is visible on MRI, then the evidence is currently pointing to these types of tumors having a higher chance of changing over time. But again in well-motivated patients, a period of active surveillance in this case would be safe probably with a greater frequency of MRI scans (we think yearly).
We then look at the individual patient in terms of suitability. Most patients, when they are told they have prostate cancer, get very worried and stressed and anxious – this is a natural reaction. Their family and their partners will equally become very anxious about monitoring any kind of cancer. It is important to know that in the majority of cases of patients who have low risk prostate cancer that having immediate treatment will not benefit you in the long term in terms of improved survival, but will inevitably carry a risk of side effects such as urinary problems and sexual problems and if you have radiotherapy, back passage problems. And so, effectively, you would be treating anxiety rather than treating the disease and you will be accepting some degree of side effects for what most agree is very little in the way of survival benefit. Once patients and their families and their partners and friends understand this and appreciate this, the vast majority of patients are willing and able and keen to go on to active surveillance. There are some patients whose just psychologically would not be able to cope with any kind of active surveillance and in these cases, clearly, it would be wrong to deny a treatment.
What happens when the prostate cancer changes and progresses on active surveillance?
If the disease does change on active surveillance, then we would normally consider what risk of disease it is at that time. Most of the time, low risk prostate cancer progresses to medium risk disease and surgery, radiotherapy and focal therapy using HIFU or cryotherapy/cryosurgery are usually options that are fully amenable at that time and you should consider all of these properly. Uncommonly, sometimes the disease can progress from low to high risk cancer and in these instances, we would recommend surgery or radiotherapy. If there is a small amount of high risk disease, which is contained in the prostate gland in one area, then focal therapy using HIFU or cryotherapy/cryosurgery can still be considered.
Provided active surveillance is carried out regularly with regular PSA tests and MRI scans as outlined above and biopsies if necessary, then the chance of the cancer spreading is very low. The key with active surveillance is that you have had a good MRI scan reported by an expert radiologist in prostate MRI and have had a high quality targeted and systematic biopsy of your prostate so that the true nature of the disease is accurately ascertained right at the beginning as much as possible. If any one of these elements is lacking, then sometimes a repeat MRI or even a repeat targeted biopsy will be required.
Can I do anything in terms of dietary or lifestyle changes to slow down any progression of prostate cancer that might happen?
There is some emerging evidence that changing diet and lifestyle can help with reduction in progression of prostate cancer, as well as preventing recurrence or reducing the chance of recurrence once you’ve had treatment. Eating more foods such as cooked tomatoes, mixed nuts (preferably without salt so that it doesn’t increase your cardiovascular risk and that you are not allergic to any of the nuts); the brassica vegetables such as broccoli, cauliflower, kale; having a cup of green tea every day or every other day; and pomegranate, either the juice, fruit, or you can buy tablet extracts. These all can help to protect the prostate. There is some evidence that reducing dairy products is also helpful. Although if you do, you must make sure you supplement calcium and vitamin D because those two elements are very important. Reductions in red meat are generally protective against many cancers and reducing the amount of processed food that you eat is also important.
Regular aerobic exercise, such as swimming, jogging, cycling, brisk walking three or four times a week, even if it’s just for 10 to 20 minutes each time, is going to be helpful and protective against cancers as well as improve your general health. And if you do need treatment in future, for any other kinds of problems, you’ll be able to better recover and tolerate those treatments as a result of improving your lung and heart function and circulation of blood through the body.
And finally, any other lifestyle problems such as smoking, you should obviously try your very best to quit smoking using all of the approved programs in the NHS or by following your doctor’s advice. You should try and reduce your weight if you are overweight or in the obesity category and this will significantly reduce cancer risk.
Are the genetic markers on the tissue or new blood tests helpful in active surveillance?
A lot of studies are being currently carried out to look at the genetic make-up of prostate cancers. There are some promising genetic markers out there which are being investigated. Currently in the UK, none are routinely approved or being used routinely for determining whether a patient is suitable for active surveillance or not. We think MRI and the biopsies are currently the two most accurate factors in determining the risk of the tumor but in future there might be genetic markers which add to that complexion of risk. Equally there are many, many blood based and urine based biomarkers which are being developed and evaluated and at the moment there are none that are being used or approved for the setting of active surveillance within the UK.
The whole field of biomarkers and genetic markers has been held back over the last three decades by the use of our previous biopsy which was a transrectal random biopsy. The reason for this is that if you compare a genetic marker or a new blood based or urine biomarker against a test that is only 50% accurate, which is what the accuracy of the previous biopsy test was, then you will get a lot of false positive and a lot of false negative results from new biomarkers that were being developed and evaluated. Many of these biomarkers now need to be tested against the new MRI and MRI targeted pathway in order to see how these fit with a much more accurate pathway for the detection of important prostate cancer.
We hope you found this information useful. If you would like to discuss your specific circumstances with Professor Ahmed, please do book an appointment or email us.
Or contact us if you wish to speak to us before booking.
Active surveillance can be carried out using high quality MRI scans and if necessary image-fusion targeted biopsy in the NHS and privately.
For NHS referrals, Professor Ahmed works at Imperial College Healthcare NHS Trust. You are entitled to ask for a referral for an opinion about whether you might be suitable on the NHS. Your GP can make the referral through the choose and book electronic referral system and choose the ‘Prostate – Established diagnosis’ folder. Your consultant team can also make the referral directly to Imperial using the email: email@example.com or letter (addressed to Professor Ahmed at Charing Cross Hospital, Fulham Palace Road, London W6 8RF).
For private referrals, Professor Ahmed works at Cromwell Hospital and Imperial Private Healthcare. Self-pay patients do not need a referral to consult Professor Ahmed. Insured patients should check with their insurer. Please use the online booking portal or email the team on firstname.lastname@example.org