These days, Active Surveillance (AS) seems to be the new best friend for prostate cancer (PCa) patients. Over 40% of newly diagnosed, low-to-favorable intermediate risk patients now begin PCa management on AS. This method defers treatment, but there’s a catch. Patients must be responsible to:

• Obtain the most thorough portrait of your PCa (multiparametric MRI, in-bore MRI-targeted biopsy of suspicious areas, family history/risk factors, genomic analysis if indicated)
• Adhere to your doctor’s monitoring schedule (PSA tests, mpMRI, repeat targeted biopsy if indicated)
• Make lifestyle choices to lower risk of PCa progression (diet, exercise, stress management, etc.)

Why do patients choose AS, knowing that PCa will still be in their bodies? It’s because they want to avoid the urinary, sexual and bowel side effect risks of surgery or radiation as long as possible. How long is that? Well, it’s as long as the PCa does not worsen—which is why monitoring is crucial.

The most important question

Currently, experts generally limit AS eligibility to patients with low-volume 3+3 tumors, or 3+4 tumors with only a small percentage of grade 4. Embarking on AS raises the most important question: How long can I expect to be on it?

Your doctor will educate you on warning signs he will monitor for, but there is one factor that can help you adjust expectations when considering AS. A clue that the switch to treatment may come sooner is a suspicious mpMRI result. For that clue, we can thank a January 2022 paper by Olivier et al, whose goal was to determine “the length of time we can defer treatment and have the patient on AS.”^[i]

The Olivier study is informative. Its database of over 21,000 AS cases was drawn from 25 international AS registries from 2014-16. From that pool, study cases were included only if they had MRI results within a certain timeframe from diagnosis. That whittled it down to 2119 cases. These were divided into two groups, whose patient and tumor characteristics were comparable (the only difference being suspicious tumor appearance on MRI at the time of inclusion):

• Nonsuspicious MRI at the time of inclusion (1035 cases)
• Suspicious MRI at the time of inclusion (1084 cases)

The data was analyzed for the length of time on AS until:
a) Active treatment (surgery, radiation, brachytherapy, focal therapy, hormone therapy) or
b) Gleason grade progression (higher grade at follow-up biopsy) or
c) Stopping AS for any reason (progression, conversion to treatment without evidence of progression, transition to watchful waiting, anxiety, non-PCa death, and other/unknown).

According to findings for the entire cohort of 2119 cases, 71% of men were still on AS at 3 years, and 60% at 5 years. These statistics help guide expectations. On average, for PCa patients considering AS, over half can expect to defer active treatment at least 5 years. However, when analyzed specifically by the two subgroups, there’s a distinct difference:

	Nonsuspicious MRI at inclusion	Suspicious MRI at inclusion
Still on AS at 3 years	82%	72%
Still on AS at 5 years	66%	52%

As you can see, those patients whose MRI was suspicious at the beginning were more likely to come off AS sooner than those without suspicion. Barely half were still on AS at 5 years, even with similar tumor characteristics between the two. This can be explained by MRI’s superior detection of tumor size and/or tumor aggression. MRI registers higher grade or bulkier disease that is more likely to progress during monitoring. If progression occurs, it triggers discontinuing AS and switching to active treatment.

This might seem like a cautionary tale for newly diagnosed patients with a suspicious MRI who are deliberating—perhaps even anguishing—over whether to go on AS. However, the Olivier paper offers reassurance, while also emphasizing the importance of vigilance: “The potential impact of these findings is that suspicious MRI does not necessarily exclude a patient from AS since a substantial number of men with suspicious MRI did not progress on AS, but it is clearly suggested that those with suspicious MRI may have to be followed more closely than a patient with nonsuspicious MRI.” In other words, better safe than sorry. We concur. In a previous blog we cite other factors that can either indicate the need for immediate treatment at the time of diagnosis, or can be detected during AS in order to switch to treatment before missing that window.

At our Center, we take pride in helping AS patients safely achieve the most successful monitoring, thanks to our state-of-the-art 3T magnet, and our pioneering excellence in real-time, in-bore MRI guided targeted biopsy if need arises. We also add regular testing for PSA and PSA density, and genomic analysis if indicated. For more information on how we can support the choice for AS, contact us.

 

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Olivier J, Li W, Nieboer D, Helleman J, et al. Movember Foundation’s Global Action Plan Prostate Cancer Active Surveillance GAP3 Consortium. Prostate Cancer Patients Under Active Surveillance with a Suspicious Magnetic Resonance Imaging Finding Are at Increased Risk of Needing Treatment: Results of the Movember Foundation’s Global Action Plan Prostate Cancer Active Surveillance (GAP3) Consortium. Eur Urol Open Sci. 2022 Jan 3;35:59-67. doi: 10.1016/j.euros.2021.11.006.