Treating Prostate Cancer By Close Monitoring or ActiveSurveillance

Prostate cancer is the most common cancer in older men and second most common cause of death due to cancer in men over the age of 50.  This year more than 180,000 men will be diagnosed with prostate cancer and more than 30,000 men will die of this disease.  There are multiple treatment options for prostate cancer including surgery, radiation, hormone therapy and now there’s a new option: watchful waiting or active surveillance.  Active surveillance means no treatment but careful monitoring with regular digital rectal exams, PSA testing, and possible other tests and\or imaging studies.  This blog is intended to help men who have received a diagnosis of prostate cancer to help guide them in the decision of active surveillance or more aggressive standard treatment options.

What you need to know

The prostate gland is a walnut-sized organ at the base the bladder and surrounds the urethra or the tube in the penis that transports urine from the bladder to the outside of the body.  The prostate gland’s function is to make the fluid that mixes with the sperm and provides the sperm with nourishment to help fertilize an egg and start the process of conception.

For the first part of a man’s life the prostate gland provides pleasure and enjoyment.  After age 50 for reasons not entirely known, the prostate gland starts to grow and compresses the tube or the urethra and produces difficulty with urination.  Again, for reasons not entirely known the prostate cells grow uncontrollably and this results in prostate cancer.

Prostate cancer is a very common as one in seven American men will develop prostate cancer.

There are two tests used to detect prostate cancer: 1) the digital rectal exam and 2) the PSA or prostate specific antigen test.  PSA is a protein made by the prostate gland.  An increased level of PSA can be a sign of prostate cancer but an elevation is also seen in men with prostate gland infections and benign enlargement of the prostate gland.

Active surveillance is now considered an acceptable management option in certain men with prostate cancer.  Active surveillance is a type of close follow up. In addition to the PSA and digital rectal exam, a repeat biopsy may be indicated.  A biopsy test called a fusion-guided biopsy is one of these newer tests that combines the MRI with real-time ultrasound images of the prostate.  Genomic tests are another development for prostate cancer assessment.  These tests look at the DNA of the cancer to decide if the cancer is stable or growing.  If any of these tests indicate that the cancer is growing, you may require additional treatment.

At the present time there is no universal agreement about how often the tests should be done for men who are participating in active surveillance.  Patients who are at low risk, that is have a low PSA and a biopsy that reveals a reasonably favorable pathology report, then he can have his PSA check every six months.  It is also common to have a repeat biopsy 12-18 months after the diagnosis.

Candidates for Active Surveillance

Men with early stage prostate cancer that is confined to the prostate gland are the best candidates for active surveillance.  Also, good candidates are men without symptoms and have prostate cancer that is slow growing.  Finally, older men with serious other medical problems which may interfere with treatment are potential active surveillance candidates.

The benefits of active surveillance is that it is low cost, safe, and has no side effects.  Men are able to maintain day-to-day quality of life and not have any of the complications of treatment such as impotence\ED or urinary incontinence.  The risk is that men can become complement and not follow up as often as they should and that the cancer can grow and become more aggressive.

Bottom Line:  Prostate cancer is a common problem in middle age and older men.  Most men if they live long enough will develop prostate cancer.  However, most men with the diagnosis of prostate cancer will die with the cancer and not from it.  My best advice is to have a conversation with your doctor and see if active surveillance is right for you and your cancer.

Prostate Cancer –Management of Low Risk Disease*

Prostate cancer remains one of the most common cancers in men with 250,000 new cases each year and causes nearly 40,000 deaths each year. Like most other cancers there are shades of gray and not all cancers need to have treatment. This blog will discuss the use of androgen deprivation therapy and when it might used in men with advanced prostate cancer.

There’s nothing like an elevated prostate specific antigen (PSA) test result to strike fear into even the most unflappable and courageous of men. That’s because elevations in PSA in the blood can point to the presence of prostate cancer. On the other hand, elevated PSA can also indicate prostatic enlargement or inflammation of the prostate. However, an elevated PSA test result, combined with a digital rectal exam and a 12-core prostate biopsy to remove small pieces of prostate tissue from the gland, will provide a very good idea as to whether a man has cancer or not.

About 40 to 50 percent of the 241,000 men expected to be diagnosed with prostate cancer this year will have a suspicious PSA score and a Gleason score of 6 out of 10, which is based on the prostate biopsy. A Gleason score of 6 is an indicator of a very favorable or low-risk disease, a disease that is treatable and curable — if, in fact, a man chooses to treat it.

Facing treatment decisions. Once a man has a prostate cancer diagnosis, he then has to choose what type of treatment he wants, which can include surgery or radiation therapy; men with low-risk cancer can also opt for active surveillance, or close monitoring without any immediate treatment. However, these men have to have a digital rectal exam and PSA test and possibly a repeat biopsy on a regular basis.

The good news is that low-risk prostate cancer — meaning low grade and low stage with a PSA below 10 ng/mL — grows slowly, if at all. Therefore, a man should be sure to discuss with his doctor whether he really needs to undergo any therapy to treat his cancer. That’s because in the majority of cases the answer will be “not now.”

What we have learned over the years with low-grade cancer is that sometimes the best option is no treatment whatsoever. And that includes treatment with androgen deprivation therapy, or ADT.
Earlier this summer, I came across a study in JAMA Internal Medicine that reminded me that many men with low-risk prostate cancer are still being offered primary ADT to treat their cancer, something that we would not recommend at Johns Hopkins. The reason: ADT offers no survival benefit for men with low-risk cancer and it causes significant side effects, including osteoporosis, diabetes and decreased libido.

Androgen deprivation therapy (ADT)–also called hormone deprivation, or hormonal or androgen ablation–is effective at turning off the body’s supply of male hormones, which prostate cells need to grow and develop. When the supply is shut off by drugs or by removing the testes, a portion of the cancer dies, tumors generally shrink, and PSA levels drop.

It’s androgens, or male hormones, that stimulate the growth of prostate tumors. The two most common androgens are testosterone and dihydrotestosterone (DHT). Since the Nobel Prize-winning discovery by Dr. Charles Huggins of the University of Chicago that prostate tumors depend on these hormones to grow, reducing androgen levels or blocking the action of androgen (androgen suppression) has become the standard of care for men with cancer that has spread beyond the prostate (metastasized) to the bones and other organs. There has also been increasing interest in using it in men whose PSA level has begun to rise after treatment with surgery or radiation (“biochemical recurrence,” an early sign that the cancer has not been eradicated).

Most urologists typically wait until there is evidence of metastatic disease before starting with ADT. There is an exception, however, and that is when we see a rapid PSA doubling time (less than six months) — because this provides indirect evidence of micrometastic disease that will develop in the next few years.

While ADT plays a significant role in the treatment of advanced prostate cancer, it has no role in the treatment of older men with low-risk cancer. Yet primary ADT is nevertheless being prescribed for one in eight men over age 65 diagnosed with localized prostate cancer.

The JAMA article. In the JAMA Internal Medicine study conducted by Grace L. Lu-Yao, Ph.D., a cancer epidemiologist at the Rutgers Cancer Institute of New Jersey and professor of medicine at Rutgers Robert Wood Johnson Medical School, more than 66,000 older men with low-risk prostate cancer were followed for up to 15 years. Dr. Lu-Yao reported that those men who received ADT lived no longer on average when compared with men who did not receive the therapy.

Prescribing ADT for these low-risk patients may decrease the high anxiety level that a patient may have due to his cancer diagnosis, however, it is necessary to note that such treatment may carry more risk than benefit. ADT helps reduce anxiety by quickly dropping PSA levels into the undetectable range, so the doctors may feel that they are doing something positive for their patients. However, ADT may not really be in the patient’s best interest due to complex side effects. The doctor should really be talking to patients with low-risk disease about pursuing active surveillance, not ADT.

There are serious potential risks associated with ADT, including coronary heart disease, and the associated high costs of the medications, the use of primary ADT should be limited to patients in the high-risk cancer group who are not suitable for, or opt not to receive, primary therapy — surgery or radiation — that has the potential to cure.
The side effects associated with ADT. In general, hormonal therapy will cause significant side effects after several months of treatment. Long-term side effects of ADT may include one, some or all of the following:
• Anemia
• Coronary heart disease
• Decreased energy
• Decrease in mental acuity
• Depression
• Diabetes
• Erectile dysfunction
• Hot flashes
• Loss of muscle mass
• Osteopenia
• Osteoporosis

Bottom Line: Many men with prostate cancer who have low risk disease or who have recurrence after treatment with radiation or surgery. This is usually detected by a rising PSA after treatment for prostate cancer that is confined to the prostate gland. These men should have a discussion with their urologists and discuss if androgen deprivation therapy is really in their best interests and that the benefits vs. the side effects are worth the treatment with androgen deprivation therapy.

*This blog was modified from the Johns Hopkins Newsletter, July 2014

Watchful Waiting May Be An Option for Low-Grade Prostate Cancer

A recent report coming from research at Johns Hopkins University demonstrated that men with very low-grade prostate cancer may be able to be observed closely for any progression and avoid or delay treatment.  The study included over 700 men with localized prostate cancer that was very low-grade or not very malignant who were followed every six months with PSA testing and a rectal exam and a prostate biopsy every year.  Since 1995 none of the men has died from prostate cancer.  One-third of the men had to undergo subsequent treat five or even 10 years later because their PSA increased for their biopsy showed a more aggressive form of cancer was present in the prostate gland.

Nearly 60 percent of men enrolled were able to defer treatment for 5 years or longer and > 40 percent were able to defer treatment for 10 years or longer. This means they were also able to defer all risks associated with active treatment (incontinence, erectile dysfunction, bowel problems associated with radiation therapy, etc.).

Bottom Line: This study offers good evidence that watchful waiting may be an option for older men diagnosed with a very low-grade prostate cancer.  However, these men must be committed to regular follow up.