The Right Way to do Active Surveillance

We know that the use of Active Surveillance (AS) as a way to hold off on prostate cancer (PCa) treatment is on the rise. Concerns about overtreatment, such as doing a prostatectomy on a patient who only has a small Gleason 3+3 tumor, stem from two recognized realities:

1. Insignificant PCa may be slow-growing (indolent) and never become life-threatening, and
2. The side effects of whole gland treatments (prostatectomy and radiation) can make life inconvenient and embarrassing, if not downright miserable.

Urologists are now having more discussions with patients about AS as a PCa management strategy, and more men are choosing it. On the other hand, AS is still underused, according to a 2015 multi-institution study.[i] This seems like a loss for thousands of men who, if they go about AS the right way, can defer treatment for years and thus avoid side effects. So what is the “right” way to do AS?

First, I want to distinguish “watchful waiting” (WW) from active surveillance. There’s a big difference between passively waiting and actively monitoring. For decades, WW was suggested for older PCa patients who were not surgical candidates and who didn’t want radiation. Since PCa was considered slow-growing, all the patient had to do was get an annual PSA test and digital rectal exam. If either showed new activity, it would trigger a decision to intervene (usually radiation or hormones). More recently, as PCa is being found in younger and younger men, WW was felt to be unsafe since PCa progression seems to be fueled by testosterone—which younger men have in higher levels that can spur cancer growth. This gave rise to the concept of AS which entails more attention, effort and energy. It means more frequent PSA tests and DRE, perhaps every 3-6 months. Also, TRUS biopsies may be advised every year or two. Today’s patients often add components such as actively changing their nutrition for the better, taking supplements shown to promote immunity and discourage tumor growth, embarking on a more strenuous exercise program, and improving stress management skills.

However, the study I mentioned raises a concern that “those who were undergoing watchful waiting/active surveillance were less likely to receive prostate-specific antigen testing and to attend office visits within the 2 years after diagnosis…” The authors describe inconsistent and confusing definitions of AS. For instance, they hypothesized that more of the patients were actually doing some form of AS but were calling it WW. The quality of monitoring was likewise varied, and often poor, though whether through lack of physician oversight or patient compliance was unknown.

Is there a recipe for doing AS the right way? There is. In addition to PSA, DRE and lifestyle changes, it includes a very important ingredient: multiparametric MRI (mpMRI) on a 3T magnet. This is the Cadillac of prostate imaging, yet most patients are never even told about it by their urologists. After a suspicious PSA or DRE, the next step before a biopsy should be a baseline mpMRI to see what’s going on in detail. When performed and interpreted at an expert facility, mpMRI can identify suspicious areas, rule a biopsy in or out, and stratify a patient’s risk even before a biopsy. Once there is a baseline record, mpMRI can be reliably used to monitor for PCa development far better than PSA alone, since a rising number can mean a number of things besides cancer. If and when a biopsy is warranted, a real-time MRI-guided targeted biopsy can precisely capture tissue from areas most likely to harbor dangerous PCa, giving the greatest accuracy with the fewest needles.

The right way to conduct AS is to take the guesswork out of it by adding the assurance of top-shelf imaging. But remember that active surveillance means taking responsibility for your health, and maximizing your body’s ability to protect itself from cancer. Multiparametric MRI is not the only ingredient for doing AS the right way – but it’s irreplaceable. Even when you’re doing all the other right things, nothing else can provide the information needed to make best decisions about biopsy, treatment and follow-up. No AS program is truly complete without it.

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[i] Chamie K, Williams SB, Hershman DL, Wright JD et al. Population-based assessment of determining predictors for quality of prostate cancer surveillance. Cancer. 2015 Aug 26. doi: 10.1002/cncr.29574. [Epub ahead of print]