Beyond doubt, the interest in Active Surveillance for prostate cancer (AS, also called Expectant Management) is on the rise. A number of converging factors are driving the increase:
- Better early detection and diagnosis of low-risk disease
- Emerging science on which cell lines are unlikely to progress into lethal disease
- Broader awareness of the risks of whole gland treatment
- Willingness to monitor in order to buy time in hopes of a new and better treatment
A new paper from a consortium of 17 Michigan urology practices (Michigan Urological Surgery Improvement Collaborative or MUSIC) reports the percentage of 682 low-risk patients who were initially placed on AS.[i] According to the paper, 49% of the men chose AS, compared with traditional rates ranging from 4-20%. 85% of the patients were monitored by PSA, but not surprisingly, only 1/3 had repeat biopsy.
According to the Johns Hopkins urology website, tracking AS using PSA is inadequate, so their program employs an annual biopsy:
Studies from our active surveillance program have shown that PSA level changes are not sufficient to alert us as to whether or not the cancer is changing. This necessitates surveillance biopsies for careful monitoring. During a surveillance biopsy, our studies show that it is necessary to sample the transition zone of the prostate (anterior prostate region), which is why we now perform a 14 core biopsy in most men undergoing surveillance. For those men that have 2 consecutive annual biopsies that show no cancer, we recommend that the interval between biopsies be lengthened to 18 months.[ii]
Our experience at the Sperling Prostate Center suggests that after a first TRUS biopsy of 10-14 needles, men shrink at the idea of having to “go through THAT again!” Perhaps this helps account for why 2/3 of the patients in the Michigan cohort did not have a repeat biopsy. Even if men believe that their life may depend on not missing a treatment window, they are not very motivated to have another TRUS biopsy.
Our Center offers state-of-the-art multiparametric MRI (mpMRI) under a powerful 3T (3 Tesla) magnet. We recommend a baseline prostate MRI for men considering AS, then a noninvasive annual MRI to observe any changes in the cancer. Johns Hopkins takes a conservative approach to MRI. According to their site, “The value of an MRI in determining the best candidates for surveillance is being studied to determine if this test can help assess cancer extent prior to enrollment.”[iii] There is ample data from Europe, Asia and academic centers in the U.S. that offer mpMRI showing the accuracy of imaging, and its role in AS. For example, it may be possible to hold off on a repeat biopsy until imaging reveals a need—and then it can be a targeted biopsy.
We welcome the idea that AS helps men avoid being overtreated, be it short or long term. And we proudly provide an essential component in the AS monitoring process
[i] Womble PR, Montie JE, Ye Z, Linsell SM, Lane BR, Miller DC; for the Michigan Urological Surgery Improvement Collaborative. Contemporary Use of Initial Active Surveillance Among Men in Michigan with Low-risk Prostate Cancer. Eur Urol. 2014 Aug 23. pii: S0302-2838(14)00777-5. doi: 10.1016/j.eururo.2014.08.024. [Epub ahead of print]