Active surveillance is a good option for men with early, less aggressive disease with few water work symptoms. As up to 90% of men with these prostate cancers, particularly those which have been PSA screen detected are unlikely to develop metastatic disease and tend to be over treated. Active surveillance is a good way to avoid or delay the side effects of interventional treatments such as surgery, brachytherapy and radiotherapy.
There is no hard and fast cut off for recommending active surveillance, this decision is normally made following a detailed and informed discussion with the oncologist. The factors are more likely to lean the decision towards surveillance are those which relate the disease being unlikely to progress to symptoms during the lifetime of that patient:-
Less aggressive tumours (low gleason grade)
Only some amounts of tumour found in the biopsy (low volume disease)
Low PSA doubling time
Little urinary symptoms
Patients are usually seen every three to four months initially with a rectal examination and a repeat PSA. It is a good idea to calculate the PSAdt each time. MRI scan is usually repeated annually along with repeat biopsy every 18 months (or more frequent in some cases). If there is evidence of progression on surveillance patients are usually offered treatment.
Lifestyle and active surveillance. There is now emerging evidence that lifestyle factors can alter the rate of progression of indolent prostate cancer and many men are happy to consider these as part of the program. (see lifestyle and prostate cancer).
The concept of active surveillance was formally described for the first time in 2001 by Richard Choo from Toronto, in a report of ‘watchful observation with selective delayed intervention for clinical, histologic, or PSA progression . Eligibility was restricted to men with clinical stage T1b-T2b disease with a Gleason Score < 7, and initial PSA < 15 ng/ml. Men were followed every 3 months for the first 2 years and then six-monthly, with digital rectal examination and PSA testing on each visit. Repeat biopsy was performed at 18 months. Indications for radical treatment were PSA progression, defined as a PSA doubling time < 2 years; histologic progression, defined as upgrading to Gleason score > 8 on re-biopsy; or clinical progression. The latest update of this study included data on 206 men, with a median initial PSA of 6.5 ng/ml. At a median follow-up of 29 months, 48 had received curative treatment, 4 had died of unrelated causes, and 154 men remained on observation.