Time to stop active surveillance?

Active surveillance (AS) is now the most common choice for men facing a diagnosis of low-risk prostate cancer, in which the tumor is confined to the prostate gland and unlikely to grow or spread. AS is not a passive option. It involves monitoring prostate-specific antigen (PSA) levels for changes and having regular digital rectal exams to check for abnormal areas on your prostate.

"You follow a firm schedule of regular testing and follow-ups, so you are constantly monitoring your condition," says urologist Dr. Adam Kibel with Harvard-affiliated Brigham and Women's Hospital. "AS is like a highway that you cruise along on, but if anything unusual happens, you can easily exit and choose a treatment option."

But can AS be a journey that lasts forever? When do you know when you should take the off-ramp?

Making the choice

The goal of AS is to defer="defer" surgery or radiation to avoid possible side effects of these treatments, such as erectile dysfunction, incontinence, and bowel function problems. The choice to follow AS begins after a prostate biopsy to identify the cancer's size and probability of spreading. "AS is a great option for men who have low-volume, low-risk cancer that hasn't spread," says Dr. Kibel.

A PSA test measures the amount of a specific protein in the blood produced by both cancerous and noncancerous prostate tissue. PSA levels are measured in nanograms per milliliter (ng/mL). In general, a PSA level between 4 and 10 ng/mL is considered the borderline range and suggests about a 25% chance of having prostate cancer. Levels higher than 10 ng/mL increase the cancer risk to more than 50%. Also, a continuous rise in PSA levels over time may be a sign of cancer.

The Gleason scale uses a 2-to-5 ranking to grade how the two most common cell types in the tumor taken from a prostate biopsy look compared with normal prostate cells. The numbers for each are added together to get a Gleason score. A grade no higher than 6 often means you have low-risk prostate cancer and will be offered active surveillance as a treatment option.

If you choose AS, the usual plan includes a PSA test and a digital rectal exam about every six months and repeat prostate biopsies approximately every other year. If your PSA level suddenly rises or your rectal exam suggests an abnormality, your doctor will also likely recommend a prostate MRI or an earlier prostate biopsy to see if the cancer has become more aggressive.

"If there's evidence the cancer has become more active, then you and your doctor will discuss treatment options such as radiation, hormonal therapy, or surgery to remove the prostate gland," says Dr. Kibel.

The waiting game

How long can you stay on AS? "Unless there's a change in your condition, you can stay on AS indefinitely," says Dr. Kibel. Men may continue on AS for 10 years or even longer.

Still, certain situations may encourage men to rethink staying on AS. One is psychological — the constant worry and anxiety that something could be wrong. "For men with a family history of aggressive prostate cancer, the prolonged wait-and-see process may become too stressful," says Dr. Kibel. "If they feel they may eventually need treatment, they may want to move forward and not wait any longer." Another similar factor is so-called AS fatigue where men tire of the constant monitoring required by AS.

Increasing age might lead someone to end AS, but without moving to treatment. If you're still on AS in your late 70s or early 80s with an estimated life expectancy of less than 10 years, you may want to consider shifting to a less intensive approach known as watchful waiting. With watchful waiting, you still may want to have periodic doctor visits. But monitoring the prostate cancer stops, including no more biopsies, in order to avoid the stress and potential side effects of continuous testing.

"The goal is to no longer cure you of the cancer but simply follow it," says Dr. Kibel. "The bet is that the cancer is so slow growing it isn't a long-term threat even if it does progress," says Dr. Kibel.

If you later develop symptoms that indicate the cancer has advanced — such as extreme fatigue, weight loss, urinary retention, or bone pain — you can consult with your doctor about your goals and what options you have to reduce cancer-related symptoms.

Ultimately, men must remember that they are always in the driver's seat when on AS. "It comes down to weighing risks and benefits and working with your doctor to determine whether staying on AS is best, or whether it's time to make a change," says Dr. Kibel.

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