Originally published 3/14/2017
What does overtreatment of prostate cancer (PCa) mean? A classic definition calls it “…an active treatment (e.g., surgery, radiation, hormones, or a combination of these) in a patient who would never have had symptoms nor have died as a result of his prostate cancer.”[i]
Thus, it’s aggressive treatment for men with insignificant PCa, putting them at risk for lifestyle impairment, be it temporary or permanent.
In such cases, Active Surveillance (AS) is now considered desirable in order to avoid risking collateral treatment damage that causes urinary incontinence and/or erectile dysfunction.
However, holding off on treatment until disease progression is discovered and confirmed by biopsy may be risky business. There is no established universal schedule for monitoring until disease progression is detected.
A 2024 study finds that the longer the delay until detection, the greater risk of PCa death. According to Yang, et al, “A 2-year delay resulted in a prostate cancer death risk of 2.46%-2.69% 5 years after progression detection and a 10-year risk of 5.75%-5.91%. A 4-year delay led to an approximately 8% greater 5-year risk and an approximately 25% greater 10-year risk.”[ii]
It’s no wonder that some patients on AS doubt their choice and come off it early. However, faithful monitoring with biomarkers and imaging means very early detection and diagnosis of PCa activity.
At our Center, for patients beginning on AS we urge regular PSA testing (starting at 6 month intervals lengthening to a year) coupled with multiparametric MRI at the first sign of a suspicious PSA result. For more details, see the original blog below.
More and more prostate cancer patients and their doctors are turning to Active Surveillance (AS). Data shows that for carefully chosen low risk patients, AS is a way to hold off on treatment like surgery or radiation without significantly increasing the chances of death from prostate cancer. Estimates suggest that at least 40% of low risk patients like this concept and embrace the strategy, and the numbers are growing.
What is AS?
Active Surveillance is different from Watchful Waiting (WW). AS requires both routine PSA tests at prescribed intervals as well as repeat monitoring biopsies – as often as every 1-2 years – even if PSA hasn’t budged. On the other hand, WW is reserved for elderly men because of their shorter life expectancy; PSA tests will be done, but no routine monitoring biopsies. Think of it as “passive surveillance” because it is much less invasive. When a patient is on AS, the doctor is also active because he is responsible to look for clinical signs that will trigger definitive treatment.
Why wouldn’t every low risk patient choose AS? Because doubts can be raised by 3 considerations:
- About 30% of low-risk patients on AS will progress to at least one Gleason 4 needle sample during short-term monitoring. How can patients be sure they have a low probability of cancer progression (becoming more aggressive) in their lifetime?
- There is not universal agreement on the criteria for patient selection, or on a protocol for deciding what triggers treatment. Is it based on an absolute PSA value, PSA movement or biopsy-proven progression?
- “Surveillance fatigue” or the psychological stress of living with unknown cancer activity has an impact on a patient’s quality of life. Many patients do not go on AS because they want “all the cancer out of their bodies” and many men on AS drop out for the same reason. However, men who seek treatment and then suffer with urinary or sexual side effects report diminished quality of life. How can a patient know in advance which stress is more tolerable?
Multiparametric MRI dispels doubt, boost confidence
A newly published article by Peter Choyke (National Cancer Institute) and Stacy Loeb (NY University) well describes how multiparametric MRI of the prostate verifies AS candidates better than TRUS biopsy.[iii] The authors write, “Performed before a patient is accepted onto an active surveillance protocol, mpMRI can identify lesions missed by the standard TRUS biopsy or can more properly characterize cancers detected at TRUS biopsy.” This acts like a great insurance policy. If the imaging does not show a suspicious lesion, or if it confirms a biopsy of Gleason 3+3, the doctor and patient can both be confident in embarking on AS. However, not all mpMRI scans are created equal, and achieving the best quality scans and interpretations is obviously paramount. The authors caution that generating the images must be done using standards set forth in the Prostate Imaging Reporting and Data System (PI-RADS) version 2. (See my blog at https://sperlingprostatecenter.com/pi-rads-score/) for background information on PI-RADS.)
Just as mpMRI validates a patient’s clinical qualifications for AS, it likewise offers what our Center knows is the monitoring method of choice. The initial mpMRI becomes the baseline scan for comparison with subsequent scans. Research repeatedly demonstrates that the combination of protocol-regulated PSA and mpMRI when PSA shows upward change offers significantly more accuracy than a TRUS biopsy every year or two. If the imaging shows a departure from the baseline imaging, an in-bore MRI-guided targeted biopsy can best determine if the time for active treatment has come. Furthermore, the imaging results are of immense value in deciding upon and planning a treatment if it is warranted.
At our Center, we adhere to the PI-RADS (v2) standards. Our 3T (3 Tesla) magnet is equipped with state-of-the-art sequences to generate information about tumor characteristics and the most important prostate cancer features. We are proud to be able to help AS candidates overcome any doubts or worries they may have. The pictures provided by mpMRI are worth a thousand words of reassurance. It is a great feeling to know that we can boost confidence for both doctor and patient, thanks to the excellence of our mpMRI for prostate cancer. With the strides that are being made in genomic analysis of molecular biomarkers, the integration of mpMRI, in-bore targeted biopsy and new genetic testing promises to take confidence to nearly 100% certainty.
If you or a loved one is considering AS for low risk prostate cancer, please contact our Center for more information.
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] Thompson IM. Overdiagnosis and overtreatment of prostate cancer. Am Soc Clin Oncol Educ Book. 2012:e35-9.
[ii] Yang Z, Heijnsdijk EAM, Newcomb LF, Rizopoulos D, Erler NS. Exploring the relation of active surveillance schedules and prostate cancer mortality. Cancer Med. 2024 Mar;13(5):e6977.
[iii] Choyke P, Loeb S. Active surveillance of Prostate Cancer. Oncology Journal, Prostate Cancer. 2017 Jan 15. http://www.cancernetwork.com/oncology-journal/active-surveillance-prostate-cancer
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
