BackTable / Urology / Article

Prostate Cancer Active Surveillance: Who, When & How

Author Ishaan Sangwan covers Prostate Cancer Active Surveillance: Who, When & How on BackTable Urology

Ishaan Sangwan • Nov 15, 2021 • 32 hits

While the idea of not treating a cancer may alarm patients, active surveillance for prostate cancer may be a patient’s best option, especially if the disease is low grade. This article discusses the criteria to start prostate cancer active surveillance, various modalities to monitor disease progression, and indications to initiate other treatment.

This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable Urology Brief

• All prostate cancer patients must be risk stratified to see if treatment is appropriate. If the patient has a life expectancy of less than 10 years, treatment may do more harm than good.

• Active surveillance is appropriate for patients with low grade prostate cancer, as confirmed by biopsy showing a Gleason 6 score and an MRI.

• Patients under active surveillance must be monitored by PSAs, biopsies, and MRIs, with subsequent treatment being initiated if there are signs of progression.

• Ablation treatment is generally not appropriate for low grade prostate cancer, as the disease poses little threat, and ablation may harm the patient.

A doctor consulting a patient about prostate cancer.

Table of Contents

(1) Risk Stratifying Prostate Cancer Patients

(2) Initiating Prostate Cancer Active Surveillance

(3) Complete Active Surveillance vs. Ablation Therapy for Low Risk Patients

Risk Stratifying Prostate Cancer Patients

Risk stratification for prostate cancer can be done according to AUA or NCCN guidelines. A patient typically benefits from treatment if they have a life expectancy of 10 years or more. However, life expectancy cannot be assessed by age alone, as some younger patients may be far less healthy than older ones, and vice versa. For borderline cases, Dr. Bagrodia recommends putting the patient’s data into a life expectancy calculator, and explaining the likelihood of actually helping them in order to help the patient make an informed decision.

[Dr. Jeff Cadeddu]
I don't do that in clinical practice. In my practice, at least it takes a little bit too much time. I also find that giving or providing data regarding nomograms to patients, the average patient, at least in Texas comes back to what you said, which is, "Doc, what would you do?" Right? So I don't find doing that. I do risk stratify everybody per AUA and NCCN guidelines, and then provide them with that information. And that the favorable and unfavorable intermediate risk, if they have a 10-year life expectancy, they would benefit from treatment at least in preventing metastasis. And if they have a long enough life expectancy would probably benefit from, in terms of dying of prostate cancer.
The high risk patient, I think, as long as they have a life expectancy of five to eight years probably would benefit from treatment. And I just kind of ballpark it for the patients. I think patients like that going into... This is the rare patient who can understand the nuances of some of those nomograms.

[Dr. Aditya Bagrodia]
Yeah. I wholeheartedly agree. I think you have to read the room a little bit and see what's going to be a digestible format for the patient. Life expectancy prediction is tricky business. We've all seen patients that are 50 that look like they're 80 and vice versa. You mentioned five years as a landmark that pops up in the AUA guidelines, 10 years. How do you assess functional status life expectancy?

[Dr. Jeff Cadeddu]
I don't assess it. Again, in the real world, I think community urologists would appreciate the fact that we don't have time to sit around and input patient data into some sort of calculator. You also realize that no patient likes to be told that they're 65 years old. There's no chance in hell they're going to live to 75. So it's nuanced. You talk to the patient and then when you do talk to the cardiologist, which is most of their comorbidities, no cardiologists will stick their head out and say, "Oh, yeah. This patient definitely will be dead in eight years."
Everything's pretty nuanced. Like you said, you have to feel the room, get a gist for the patient's health. If you've got a history and the patient is 70 years old and has diabetes and hypertension and coronary artery disease, I think you have to have a discussion where, okay, well, you might really not get the long term benefit of surgery.
I think that the greatest benefit of surgery is a really long-term. That's 15-year disease free survival. So those patients, it's a pretty easy conversation. Also, it's hard to find it's a 55-year-old who similarly doesn't think they're going to live to 65. So I don't calculate anything, but you can have a co-morbidity discussion with the patient and weigh the benefits of radiation versus surgery.
And in the occasional patient, even active surveillance. But all the nomograms in the world, I think most people in a busy clinical practice will agree that there's still the art of medicine, the nuances of counseling patients and the gestalt of how they're doing. I think patients are honest with themselves and then we'll come to the realization of what may benefit them best.

[Dr. Aditya Bagrodia]
I wholeheartedly agree. I think it goes into, we're trying to convey a message. If I've got a patient that's 77 with a little bit of grade group two prostate cancer, and they want something done, that's the guy that I pull up the life expectancy calculator, put in their history of have you had a TIA, a stroke or is your blood pressure okay? Here's your cancer characteristics. And then this little box pops up. There's a hundred people and it says three men will be dead of prostate cancer. 80 are going to be dead of something else, and seven are going to be alive.
Then I have some ammo to go in and say, "Listen, my bar to help you is 3% and my bar to hurt you is fairly tremendous as soon as I walked through what surgery radiation looks like.

Listen to the Full Podcast

Management of Localized Prostate Cancer with Dr. Jeff Cadeddu on the BackTable Urology Podcast)
Ep 16 Management of Localized Prostate Cancer with Dr. Jeff Cadeddu
00:00 / 01:04

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Initiating Prostate Cancer Active Surveillance

The first step before starting prostate cancer active surveillance is to go through a confirmation process with a secondary biopsy. Then, an MRI should be obtained after 6-8 weeks, and if the lesion is confirmed, a PSA should be obtained every 6 months. The guidelines recommend getting a biopsy again in 24 months, but Dr. Cadeddu prefers to get one within 12 months. If the biopsy comes back with a Gleason 6 score, the patient can go into active surveillance, with a PSA every 6 months and an MRI every year. If there is a new lesion or a change in lesion, a follow-up biopsy can be performed.

[Dr. Jeff Cadeddu]
Right. So everybody, if they haven't had an MRI, they definitely get an MRI once they come back to see me. Again, I think I do try to practice the guidelines in the sense that someone newly diagnosed with low-risk prostate cancer is just that they're diagnosed with it, but the first step before you would consider active surveillance is to have to go through a confirmation process.
So active surveillance for me, doesn't start until they undergo a confirmatory evaluation. And of course that means confirmatory biopsy for most patients. Only after that second confirmatory biopsy, would I then offer the patient with confidence active surveillance. So I make a very big distinction about that to my patients. So if they have systematic biopsies coming from the outside Gleason 6 and two cores, three cores, I will tell them, "Okay, let's wait about six to eight weeks. We'll get an MRI. If we see a lesion on the MRI, we'll get a PSA every six months and we'll probably repeat the biopsy somewhere between six and 12 months. Guidelines say 24 months."
And if that confirmatory biopsy is Gleason 6, then they embark on active surveillance. If they come in with an MRI already prior to the biopsy, high res three lesion or no lesion, someone did a biopsy anyway, and you have Gleason 6. Well, then I feel a little bit better, but I still would ask the patient to get a confirmatory biopsy within 12 to 24 months per guidelines.
So to me, there's a confirmatory window where they are leaning towards active surveillance, but they need to have that confirmation biopsy. Once they get that confirmation biopsy and it confirms Gleason 6, then my practice is PSA every six months. And if they have an MRI, probably I think that the pendulum is going where they'll probably have an MRI, at least in the beginning every year.
And if there's a change in the lesion, a biopsy, if there is a new lesion that wasn't there before biopsy, and then a follow-up biopsy, again, for guidelines is anywhere between two and five years after the confirmatory biopsy. So then it just depends on where the PSA or MRIs change. I think that's how most people are practicing now.

[Dr. Aditya Bagrodia]
Yeah. Very similar to me. Once they've had their confirmatory biopsies, PSA is every six months. At 18 months, they get an MRI. If that looks fine, continue on with PSA's at three years, repeat an MRI. And pretty much at that time, they're going to get a biopsy.

Complete Active Surveillance vs. Ablation Therapy for Low Risk Patients

While the topic is still medically and politically complicated, Dr. Cadeddu does not recommend ablation therapy for low risk patients who qualify for active surveillance. Data show that these patients do not have bad outcomes without treatment 15 years into active surveillance. However, if there is progression, as monitored by active surveillance, appropriate treatment should be initiated. Things that trigger reassessment and treatment include a PSA higher than 10, and upgrading or upstaging on MRI or biopsy.

[Dr. Jeff Cadeddu]
This is as much medically complicated and as politically complicated in terms of how to deal with focal therapy or ablation of the prostate. My feeling is that in the low risk patient who qualifies for active surveillance, I don't see any reason that that patient should to go any kind of treatment, whole bland, focal ablation, what have you. We have 15-year active surveillance protocols results for these patients where they didn't have any of these treatments and they're all alive and they're all fine.
So I don't know why you'd treat something that's not a threat. We don't treat other conditions that don't progress. I think if there's progression, then they should undergo the appropriate treatment for that progression. And I don't think they need to undergo focal therapy for something that's low risk.

[Dr. Aditya Bagrodia]
And what are those triggers for treatment in your practice?

[Dr. Jeff Cadeddu]
So rising PSA, right? So certainly we know that as soon as their PSA goes over 10, it's no longer low risk. So if the PSA is trending towards that, I think that's a concern, the PSA philosophy, right? We can have upgrading on subsequent biopsy, MRI biopsy. So my triggers would be either upgrading or upstaging either by MRI or PSA progression.

[Dr. Aditya Bagrodia]
Right. We're fortunate to have a really tremendous team offering MRI inboard biopsies, MRI ultrasound fusion biopsies. And let's say they've been five or six cores coming out of a single lesion that are all grade group six, patient is little nervous. How do you handle that, that situation?

[Dr. Jeff Cadeddu]
If you have a lesion in your biopsy 10 times, you'll have 10 of 10 cores, if it's all Gleason 6, right? The number of cores in targeted biopsies are done to increase the yield, but the number of cores themselves should not drive the decision-making. Right? So I would say if they have a five millimeter, PIRADS 3, PIRADS 4 lesion on MRI, and you have three out of three cores that are Gleason 6, it's probably reliable.
If it's a 17 millimeter lesion on MRI and you have three cores and three out of three are Gleason 6 may not be as reliable, right? So this is no different than kidney tumor biopsy now. So the number of cores, I think, is also relative to the size of the lesion. And I think that would influence how you counsel the patient.

Podcast Contributors

Dr. Jeff Cadeddu discusses Management of Localized Prostate Cancer on the BackTable 16 Podcast

Dr. Jeff Cadeddu

Dr. Jeffrey A. Cadeddu is a practicing Urologist in Dallas, Texas and is affiliated with multiple hospitals in the area, including Veterans Affairs North Texas Health Care System-Dallas and UT Southwestern Medical Center.

Dr. Aditya Bagrodia discusses Management of Localized Prostate Cancer on the BackTable 16 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, September 22). Ep. 16 – Management of Localized Prostate Cancer [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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