Prostate-specific antigen (PSA) testing of middle-age men to screen for prostate cancer has led to more cases being detected at an early stage. The common occurrence of prostate cancer indicates that many of these men will die with prostate cancer rather than of the disease.
“We recognize that anywhere from 30 to 50 percent of prostate cancers diagnosed by PSA testing are slow to develop and pose little-to-no threat of spreading,” says urologist Robert Reitner, MD, director of UCLA’s Prostate Cancer Program.
That is important information for both patients and physicians to consider when discussing treatment options. While treatment of prostate cancer with surgery or radiation therapy is effective in curing patients, it comes with the risk of significant side effects that can include erectile dysfunction and urinary incontinence. As a result, Dr. Reiter explains, “The goal has long been to try to better understand which patients need treatment and which ones don’t.”
The concept of “active surveillance” began as an effort to reduce the overtreatment of prostate cancer by identifying patients who are at very low risk of having their disease progress to the point that it will threaten their health. In the past, electing to not treat identified prostate cancer was referred to as “watchful waiting.” The updated term reflects a more vigilant approach to monitoring patients through periodic biopsies so that if the disease does begin to pose a threat, or if the initial diagnosis was inaccurate, the patient can still be successfully treated.
The ability to determine which patients can be placed under active surveillance rather than undergoing treatment has greatly improved, Dr. Reitner notes. In making decisions about whether to treat the cancer, doctors and patients are benefitting from a better understanding of the pathology of the tumor (Gleason score), which can be factored along with age, overall health and family history.
Magnetic resonance imaging (MRI) has been used at UCLA since 2004 as a diagnostic tool, and research by Dr. Reitner and others has shown that in combination with biopsy results, MRI can determine the risk level of prostate tumors better than the biopsy alone. Genomic testing is now available to further clarify the likelihood of the cancer progressing.
Targeted prostate biopsy is another major advance that is guiding the active surveillance effort. The approach uses MRI to identify suspicious areas of the prostate, then fuses the findings with real-time ultrasound in a special device. This not only allows for targeting of the suspicious area for the biopsy, but for patients found to have prostate cancer, it also enables the urologist to return to the same area over time to determine how fast the cancer is growing.
In 2009, UCLA started the Active Surveillance for Cancer of the Prostatic program, using targeted biopsies to more accurately classify and monitor patients. More than 500 men are currently enrolled. “The targeted biopsy gives us more confidence that we are enrolling the right people in the program, and not letting a serious cancer go untreated,” says Leonard S. Marks, MD, the UCLA urologist who heads the program.
Dr. Marks notes that as many as 30 to 50 percent of men with newly diagnosed prostate cancer are candidates for active surveillance, which is generally recommended for men with a Gleason score of no more than 6 and a small volume of tumor that has low metastatic potential. After the initial targeted biopsy, men in the program are given a repeat biopsy within six months, and if that shows no cause for concern, future biopsies are scheduled for roughly every two years.
“Anxiety is the number one driver that makes men go from active surveillance to active treatment,” Dr. Marks notes. “But the targeted biopsy provides some reassurance for the anxiety because it’s much more accurate than the conventional biopsy. This is a very personal decision. But most men who are properly categorized to go into this program won’t ever need surgery.”