Active Surveillance at the Smilow Comprehensive Prostate Cancer Center

Below you will find answers to frequently asked questions about active surveillance for prostate cancer at the Smilow Center.

• What is active surveillance, and what are its advantages?
• Who is a candidate for active surveillance?
• Is there a chance that active surveillance may compromise the ability to cure a potentially lethal cancer?
• How can I be assured that my cancer is low risk?
• If I choose active surveillance, what criteria would lead to active treatment?

What is active surveillance, and what are its advantages?

Because of widespread PSA screening, lowering of the PSA threshold for a prostate biopsy and extended biopsy protocols, we now have the ability to detect some small prostate cancers that are not likely to cause serious consequences. Men with these small cancers who have life expectancies under 10 to 15 years may wish to consider active surveillance.

Active surveillance can be thought of as avoiding or deferring treatment of prostate cancers that are not likely to be biologically significant, with the aim of avoiding or deferring the side effects of treatment. It involves carefully following the progression of prostate cancer in men who have tested positive for the disease by biopsy (Carter HB et al. J. Urol. 178:2359-2364 (2007); Klotz L. J. Clin. Oncol. 2005; 23:8165-8169). Men on active surveillance undergo follow-up PSA tests every 6 months and follow-up biopsies once a year. Curative treatment is offered only if there is evidence that the disease is progressing. In this scenario, the unnecessary side effects of treatment are avoided or deferred.

Who is a candidate for active surveillance?

Active surveillance may be an attractive option for some men who are more concerned about the consequences of treatment than the inherent risk of deferring or avoiding treatment. Although there is not yet a consensus in the medical literature on active surveillance, the Smilow Center recommends active surveillance for men with low-risk disease and a life expectancy under 10 years. We define low-risk disease as a PSA below 10, a Gleason score of less than 7 and a clinical stage of T1c or T2a.

For men with life expectancies of 10 to 15 years and low-risk disease, we offer active surveillance only if further diagnostic measures such as MRI and saturation biopsy confirm that the cancer is low risk.

Is there a chance that active surveillance may compromise the ability to cure a potentially lethal cancer?

The Smilow Center has conducted a study of the surgical specimens of men with low-risk disease undergoing radical prostatectomy who would be considered candidates for active surveillance (Mufarrij P, Sankin A, Godoy G, Lepor H, unpublished data). This study demonstrated that over 70% of men with seemingly low-risk disease were found to have intermediate- or high-risk disease at the time of immediate radical prostatectomy. The determination of risk before surgery was based on PSA, DRE and Gleason score; after surgery, it was based on tumor volume, Gleason score and evidence that the cancer had spread beyond the prostate capsule.

In addition, approximately 15% of the men with presumed low-risk disease developed a biochemical recurrence after radical prostatectomy, indicating that their disease was not curable at the time of initial treatment. It is unreasonable to assume that deferring curative intervention does not compromise survival outcomes for a subset of men with ‘low–risk’ disease who select active surveillance. The challenge is to identify these men prior to embarking on active surveillance.

How can I be assured that my cancer is low risk?

It is not possible to guarantee that anyone truly has ‘low-risk’ disease. All men undergoing active surveillance at the Smilow Center are advised to undergo a saturation biopsy and a contrast-enhanced MRI of the prostate before pursuing this course of action, since we believe these measures will identify many of the cases who might be compromised by an active surveillance regimen. Additionally, new tests are available from Aureon which can further estimate the risk of prostate cancer cells in the biopsy specimen.

If I choose active surveillance, what criteria would lead to active treatment?

Active treatment should be considered if there is a significant increase in the PSA level, a change in the digital rectal examination or a prostate biopsy that shows an increase in the grade of the cancer or in the volume of the cancer within the gland. The decision to pursue active treatment will also be heavily influenced by life expectancy.