Watchful Waiting / Active Surveillance
for Prostate Cancer
Leonard S. Marks, M.D.
Medical Director, USRF
Clinical Professor of Urology, UCLA
February, 2008---Many cases of prostate cancer do not need treatment, because they are harmless, so indolent they do not threaten the individual. For men who harbor tiny, slow-growing lesions, watchful waiting or active surveillance (preferred term) is often preferable to treatment with surgery or radiation. Because of widespread PSA testing and ease of biopsy, non-threatening prostate cancers are now found with increasing frequency. Currently, candidates for active surveillance constitute approximately half of all men with newly diagnosed prostate cancer.
The Over-Treatment Concern
As a result of widespread PSA testing, many prostate biopsies---as many as one million annually in the U.S.--- are now performed. Consequently, many incidental cancers, which would have remained undetected and clinically irrelevant in the pre-PSA era, are now being brought to light. Most prostate cancers diagnosed today are classified as Stage T1c, meaning the biopsy was driven purely on the basis of a PSA elevation and no palpable abnormality is present. While many important cancers are detected at this stage (T1c), over-treatment of non-important T1c prostate cancers is now a concern.
Dr. Jonathan Epstein, who has studied prostates removed by Dr. Patrick Walsh and colleagues at Johns Hopkins University, was among the first to recognize that many radical prostatectomy specimens contained very small cancers. Small well-differentiated tumors, i.e., those less than 0.5 cc in volume, are very unlikely to ever become clinically manifest, according to work from Professor Stamey at Stanford University in the 1980s. Thus, several investigators have followed Epstein’s lead in correlating clinical findings with pathologic findings in the whole-prostate, aiming to avoid surgery for unimportant cancers.
Establishing an Active Surveillance Program
Criteria for Active Surveillance
Dr. Michael Kattan now of Memorial/Sloan-Kettering Cancer Center in New York recently published a nomogram to help men with small foci of prostate cancer determine their risk. Data to create the nomogram were taken from a large sample of British men with prostate cancer diagnosed in the early 1990s, who were followed for many years without treatment. While the database is not perfectly applicable to U.S. men diagnosed nowadays, it is a generally helpful instrument providing an analytic approach to this problem. Specific patient examples, where the Kattan nomogram is applied to predict risk, are given here.
Patient Anxiety and the Decision for Active Intervention
Kattan MW, Cuzick J, Fisher G, Berney DM, Oliver T, Foster CS, Møller H, Reuter V, Fearn P, Eastham J, Scardino PT. Nomogram Incorporating PSA Level to Predict Cancer-Specific Survival for Men With Clinically Localized Prostate Cancer Managed Without Curative Intent. Cancer 2008 Jan;112(1):69-74
Latini DM, Hart SL, Knight SJ, Cowan JE, Ross PL, DuChane J, Carroll PR and the CaPSURE™ Investigators. The Relationship Between Anxiety and Time to Treatment for Patients With Prostate Cancer on Surveillance. J Urol. 2007 Sept;178:826-32
Carter HB, Kettermann A, Warlick C, Metter EJ, Landis P, Walsh PC, Epstein JI. Expectant Management of Prostate Cancer With Curative Intent: An Update of The Johns Hopkins Experience.
Roemeling S, et al., Active Surveillance for Prostate Cancers Detected in Three Subsequent Rounds of a Screening Trial: Characteristics, PSA Doubling Times, and Outcome, Eur Urol (2006), doi:10.1016/j.eururo.2006.11.053
Klotz L. Active Surveillance with Selective Delayed Intervention Using PSA Doubling Time for Good Risk Prostate Cancer. European Urology 47 (2005) 16-21
Cooperberg MR, Lubeck DP, Meng MV, Mehta SS, Carroll PR. The Changing Face of Low-Risk Prostate Cancer: Trends in Clinical Presentation and Primary Management. JCO 04 Jun;22(11):2141-49
Carter HB, Walsh PC, Landis P, Epstein JI. Expectent Management Of Nonpalpable Prostate Cancer With Curative Intent: Preliminary Results. J Urol. 2002 Mar;167:1231-34.
Epstein JI, Walsh PC, Carmichael M, Brendler CB. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA 1994 Feb;271(5):368
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