The Challenge of Deciding When to Treat Prostate Cancer

Despite how common prostate cancer is most men who are diagnosed with prostate cancer will not die from the disease. There are multiple reasons why the outcome for those diagnosed with prostate cancer is excellent including very effective treatments such as radiation therapy or surgery and factors specific to prostate cancer that make it unique. Prostate cancer, like most malignancies, exists on a spectrum of aggressiveness where some cancers require immediate and aggressive treatments while others may require no treatment at all. So the question becomes when should prostate cancer be treated and if it is not what is the correct follow-up?

When should prostate cancer be treated?

To know when prostate cancer does not need immediate treatment it is best to know when it does require treatment. Prostate cancer, like all cancer, is staged based on multiple factors from Stage 1 through stage 4. However, prostate cancer is also divided into the following risk groups: low risk, favorable intermediate risk, unfavorable intermediate risk, and high-risk disease. In prostate cancer what risk group you are in drives treatment and you may hear your clinical team speak more about the risk group compared with your stage.

Your risk group is not arbitrarily decided but is made up of three components. The first is the PSA value. There are cutoffs for each group but in general the higher the PSA the more likely you will have a higher risk group for prostate cancer. The second is the Gleason score. The Gleason score is the way cancer appears under the microscope and the higher the number the more aggressive the cancer appears. The final factor used to place you in a risk group is the way the prostate feels on examination or the clinical stage of the cancer. The combination of these three pieces of information will determine which risk group you fall into.

RELATED: Guide to Prostate Cancer: Overview

For men with high risk and unfavorable intermediate-risk prostate cancer who are in good health, there is little debate that aggressive treatment is needed. Treatment is also recommended for almost all cases of favorable intermediate-risk prostate cancer. Treatment for these cancers would be either radiation, surgery, hormone therapy, or a combination of these treatment factors.

In men who meet all criteria for low-risk prostate cancer, there is an option that avoids aggressive treatment and is called Active Surveillance. It is this group of men who may not require immediate treatment.

Why should I consider avoiding treatment with low-risk prostate cancer? It's still cancer.

Yes, even if you have low-risk prostate cancer this is still cancer and has the potential to become more aggressive. However, all treatments for prostate cancer are associated with side effects and by avoiding aggressive treatment these side effects can also be avoided.

Briefly, radiation therapy is associated with erectile dysfunction, urinary urgency and frequency, and changes in bowel habits. Surgery is associated with erectile dysfunction and urinary incontinence or leakage. By taking an active surveillance approach these symptoms may be avoided entirely or postponed for many years until the cancer grows or becomes more aggressive. This can lead to improved quality of life over immediate treatment.

What is Active Surveillance?

First, Active surveillance is active! This is approach is not watchful waiting or doing nothing but is a method to closely monitor prostate cancer. If the prostate cancer begins to grow, become more aggressive, or you desire treatment these are all reasons to stop active surveillance and begin treatment for cancer.

Active surveillance consists of at least bi-annual PSA assessments as well as annual digital rectal examinations, and repeat biopsies no more frequent than once per year. Additional tests may also be ordered like a prostate MRI or genetic testing with Decipher Genomics. This approach allows doctors to keep a very close eye on the cancer. If the cancer remains low risk and does not show signs of growth or an increase in aggressiveness you can continue with active surveillance and avoid the side effects that come with treatment.

Studies have shown that in properly selected men with low-risk prostate cancer about half of men who have active surveillance will be able to avoid unnecessary treatments. These same studies show that in properly selected men with low-risk cancer there is no difference in survival between active surveillance and immediate radical treatment as both options have excellent outcomes given the relative non-aggressive nature of low-risk disease.

The take-home message.

Prostate cancer is the most common cancer in men, but outcomes are excellent due to very effective treatment options. Certain me with low-risk prostate cancer may be able to avoid the side effects that are associated with treatment by choosing an active surveillance approach. You should discuss with your treating team all of your options and learn about their experience and approach to active surveillance.

 

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