One’s first reactions when receiving the dreaded diagnosis of cancer is can it be cured and what type of treatment is necessary? According to a new UCLA study, merely observing men with very low or low risk prostate cancers may be the best course of action. Watchful waiting or active surveillance, which is termed expectant management, is an appropriate approach for many men with localized tumors; it avoids the devastating side-effects of aggressive treatments (surgery and/or radiation) that are unnecessarily for many cases.
The authors note that since PSA screening tests have become widely available, most men with prostate cancer are now diagnosed with localized, low-risk prostate cancers that are unlikely to kill them. However, almost all of these men undergo surgery or radiation, which places them at risk for long-lasting side effects such as erectile dysfunction and compromised urinary function. Up to 40% of patients may currently be overtreated for their cancer, noted senior author Mark Litwin, MD, professor and chair of UCLA Urology.
Dr. Litwin said, “This study is the most up-to-date and comprehensive review of expectant management of prostate cancer patients worldwide. This represents an important resource for patients and providers considering surveillance for prostate cancer. Active surveillance and other observational strategies have produced excellent, long-term disease-specific survival and minimal morbidity for men with prostate cancer. Despite this, expectant management remains underused for men with localized prostate cancer.”
The research paper clearly outlines a number of aspects of expectant management for men with low-risk prostate cancer. First, the UCLA team clarified the definitions of types of surveillance; thus, making it easier for physicians and their patients to decide which treatment is best for them. Active surveillance entails repeated PSA testing and prostate biopsies to monitor for development of more aggressive disease in younger, healthier patients who might benefit from delaying treatment. Watchful waiting avoids aggressive testing and monitors for any physical symptoms of progressive disease. It is generally reserved for avoiding treatment altogether for older, sicker patients who will most likely die from something else.
The review study describes the current surveillance protocols, and reviews the outcomes for each of these strategies in regard to cancer survival and quality of life. In addition, it addresses new technologies such as prostate MRI and fusion biopsies, which may be beneficial for surveillance patients. “Considerable questions remain regarding both the identification of optimal candidates for surveillance, as well as understanding the ideal monitoring strategy after the initiation of observational protocols,” explained co-author Leonard Marks, MD, a UCLA professor of urology. He added, “Using strict inclusion criteria for very low-risk or low-risk prostates cancer can select a group of prostate cancer patients for active surveillance who would avoid the side effects of therapy while experiencing comparable survival and quality of life.”
Dr. Marks noted that additional work is required to optimize the delivery of these expectant management strategies for patients treated in certain settings that may not have incorporated active surveillance into their treatment protocols. Despite increased adoption of expectant management, active surveillance currently remains broadly underused and more data will be required to clarify the factors contributing to this approach.
Aside from skin cancer, prostate cancer is the most frequently diagnosed cancer in men. An estimated 233,000 new cases of prostate cancer will be diagnosed in the US in 2015. Among those, nearly 30,000 men will die. It is estimated that more than two million prostate cancer survivors are living in the US.
