What is Active Surveillance for Prostate Cancer?

Until about 10 years ago, most men with prostate cancer were immediately treated with surgery or radiation therapy, according to the National Cancer Institute (NCI). While effective in addressing prostate cancer, these treatments also put patients at risk for lifelong side effects, such as urinary problems and erectile dysfunction, that impact their quality of life.

Today, more patients with prostate cancer have instead opted for active surveillance, a process that closely monitors the cancer over time instead of treating it right away. From 2010 to 2018, the use of active surveillance increased to approximately 60% for patients with low-risk prostate cancer and 20% for those with favorable intermediate-risk prostate cancer, a study published this year in JAMA Internal Medicine found.

About 1 in 8 men will be diagnosed with prostate cancer in their lifetime — the most common cancer in men besides skin cancer, according to the American Cancer Society. But while it is common, research shows that it tends to grow slowly. For some patients with prostate cancer, active surveillance offers them an option to delay treatment until the cancer progresses, explains Dr. Joseph Alukal, a urologist at NewYork-Presbyterian/Columbia University Irving Medical Center.

“The goal is to avoid the side effects associated with treatments that are more aggressive while observing over time that the cancer remains stable in size and confined to the prostate,” says Dr. Alukal, who is also an associate professor of urology at Columbia Vagelos College of Physicians and Surgeons. “The uptick in active surveillance may be the recognition that not everybody with prostate cancer is served by being treated right away with surgery or radiation therapy.”

Health Matters spoke with Dr. Alukal to understand what it means to be on active surveillance, who is eligible for it, and what to keep in mind.

What does the process look like for a patient on active surveillance?
Dr. Alukal: A patient will regularly visit their healthcare team and be administered tests that can help monitor the cancer over time. These tests may include:

• A prostate-specific antigen (PSA) blood test every 6 months. PSA is a protein released into the blood by the prostate, and low amounts may be found in the blood of healthy people. The amount of PSA in the blood tends to increase as the prostate enlarges with age. But it may also rise because of other factors, like prostate cancer.
• A digital rectal exam at least once a year. This is a manual test that allows a doctor to feel for any abnormal bumps that might indicate cancer growth.
• Imaging tests, such as a transrectal ultrasound or an MRI, done approximately every year or if results of the PSA and digital rectal exam show any changes.
• A biopsy of the prostate after the first year on active surveillance to make sure that the cancer has not grown or spread. This also helps recalculate a patient’s Gleason score (see box).

Risk Group

Grade Group

Gleason Score

Low/Very Low

Grade Group 1

Less than or equal to 6

Intermediate (favorable)

Grade Group 2

7 (3+4)

Intermediate (unfavorable)

Grade Group 3

7 (4+3)

High

Grade Group 4

8

Very High

Grade Group 5

9-10

Who is recommended for active surveillance? Are there people who may not be able to be on it?
Active surveillance is an option for patients with low- or intermediate-risk prostate cancer, according to the NCI, meaning they have a PSA level of less than 10 and are in Grade Group 1 (Gleason score 6).

Upfront treatment is recommended for patients with high-risk disease. Patients with a positive family history or genetic risk factors for prostate cancer would also be treated immediately.

Are there risks that can come with being on active surveillance?
The idea of living with cancer and not actively treating it can be tough to cope with. One of the side effects to keep in mind when suggesting active surveillance to patients, and as we follow them over the subsequent years, is the psychological impact it could have. We always recommend speaking with a mental health professional. Some patients could be worried about cancer progression, for example, and that is the part I recognize generates anxiety in people. But we have studies showing us that the number of people on active surveillance who experience cancer progression is close to zero.

And while the treatment of prostate cancer, such as surgery and radiation, does cause side effects that people have to live with, prostate cancer itself, if limited or confined to the prostate, tends not to.

How long can someone be on active surveillance?
A person can be on it until any changes in the nature of the cancer is observed, such as if MRI imaging demonstrates a growing volume of cancer or if a repeat biopsy shows more aggressive cancer. This should prompt treatment.

For example, let’s imagine that I’m 10 years in with a patient, and every year his PSA had stayed the exact same as it was the year before. His MRI looked the same: a small focus of cancer in our biopsy early on had shown us that he had low-risk prostate cancer. And then one year he comes in and his PSA has gone up, and his MRI looks different. Maybe there is more than one area that is suspicious for cancer, or the prior area we saw had grown, and we repeat a biopsy, which is the correct next thing to do, and it shows that now his cancer has progressed and is more aggressive, either intermediate or high risk. At that point, we would start to treat him.

What are the treatments at that point?
Treatment options include surgery, radiation therapy, cryotherapy, hormone therapy, and chemotherapy.

Surgery involves removing the entirety of the prostate. With radiation treatment, the prostate remains in the patient’s body; the radiation removes the cancer but causes the rest of the prostate to change (shrink up). Sometimes patients can see the effect of radiation in their bladder, which is right next to the prostate, or the patient’s rectum, right behind the prostate. Radiation therapy rarely causes cancers, but it can cause a change in the way a person urinates or defecates.

But every year, radiation therapy gets better as well. The computers they use that target only the prostate do a million times better job compared to years ago. That is a big step forward.

Hormonal therapy reduces the levels of male hormones (androgens) in the body or stops them from increasing prostate cancer cell growth. Cryotherapy uses cold temperature to remove or freeze the cancer cells in the prostate.

And because an MRI can now show us the portion of the prostate that is cancerous, we can target just that area with one of these treatment modalities. That is also a good way to avoid some of those first side effects, like leaking urine and problems with erections and ejaculating.

There are also various kinds of chemotherapy for prostate cancer. Some of them are hormonal, some of them are not. And they are reserved for people whose cancer has spread outside of their prostate. In those cases, things like treatment with surgery to remove the prostate or radiation therapy only to the prostate would be ineffective if that cancer’s already someplace else. While they do not work forever, chemotherapy tends to work well, and we have new and better chemotherapy drugs every year.

What should people keep in mind in terms of being on active surveillance?
If a patient is seeing a doctor who is not talking to them about active surveillance, they should ask them. If the doctor is not comfortable with having that discussion, the patient should get another opinion.

The opposite is, if the patient is being told that they should do active surveillance and they are uncomfortable with or anxious about the decision, they should tell the practitioner. They should go over other treatment options and maybe go for a second opinion, so that they can become more comfortable with the option that they choose.

Slowing down and asking these questions can help patients decide on a treatment route that they are comfortable with. I want people to understand that with prostate cancer, rarely does somebody have to rush to decide about treatment; research shows this. When I hear about a disease that someone on average can live with for 15 years, most of the time, taking a month or two to try and sort which treatment option to take is safe.

Now that there is a way to follow what is going on in the prostate that does not necessitate aggressive treatment, providers are deploying active surveillance and patients are choosing it. As providers, we are seeing if we can get people to make this choice safely when they do not need surgery or radiation. That is the cornerstone that we built the concept of active surveillance on.

Joseph Alukal, M.D., director of the Men’s Health Program at NewYork-Presbyterian, is a urologist at NewYork-Presbyterian/Columbia University Irving Medical Center and NewYork-Presbyterian Westchester. He is also Andrew Sabin Family Foundation Associate Professor of Urology at Columbia University Vagelos College of Physicians and Surgeons.