If you have been diagnosed with prostate cancer, know that many options for treatment are available. Know, also, that at large teaching hospitals you will probably have a multidisciplinary team of providers. They will have examined and measured and quantified your cancer to the point where they can predict its behavior to a high degree of accuracy. Because of diagnostic testing they know the tumor’s location, the likelihood of its spreading, whether it has already spread, whether it’s fast- or slow-growing, and many other characteristics. These determinations guide treatment options for you.
Be sure to seek out an expert for your treatment. Multidisciplinary teams are great because you get a group of doctors working to treat you. However, studies have shown (surprisingly) that multidisciplinary teams don’t improve cancer outcomes. Experts in the field do improve outcomes, even if they are working independently.
Your cancer team has many treatments available, and they mix and match them to fit your needs. Three large categories are available:
- Surgery
- Radiation
- Medicine
Not all prostate cancer requires these heavy-duty treatments. It might surprise you to learn that some men choose no treatment at all except for testing. But this route is not for everyone.
Active Surveillance
The no-treatment route is often called active surveillance. It is for patients who fit certain criteria.
- Patients with low-grade, slow-growing tumors confined to the prostate gland
- PSA values must be below 10
- Patients with a Gleason score of 6 and maybe with a score of 7
Candidates, good and bad
You are a good candidate for active surveillance if:
- Your cancer is confined to the prostate;
- Your tumor is small (less than 1 cm on MRI)
- You have no symptoms;
- You can live with cancer;
- You value present positive quality of life over negative long-term consequences;
- You might have other health problems, such as severe heart disease, that limit your life expectancy and could be aggravated by prostate cancer treatment.
You are not a good candidate if:
- Your cancer is localized in the prostate at intermediate or higher risk of progression;
- Your PSA level is more than 10
- Your Gleason score is 4+3 or higher
- Your are immunosuppressed
If you are a good candidate, you will need to weigh two difficult options:
- You get treatment that could decrease your quality of life;
- You don’t get treatment, but the window of opportunity for treatment will eventually close.
How active is active surveillance?
If you choose active surveillance, you will be at the doctor’s office often. You will probably have:
- A PSA test every three-six months;
- An MRI every year
- A digital rectal exam at least once a year;
- A follow-up biopsy within six to 12 months of diagnosis; after that, at least every two to five years
If the cancer progresses, it is recommended you get treated for a cure with one or more of the following treatments:
- Surgery to remove the prostate (link to)
- Radiation therapy (link to)
- Hormone therapy and radiation therapy
Risks of active surveillance
Of course, active surveillance comes with risks, too.
- You may experience anxiety.
- You must be willing to make and keep frequent medical appointments.
- The cancer may grow.
- You may be left with fewer, more drastic treatment options if the cancer spreads.
Other considerations for active surveillance
Cost-effectiveness
In 2016 a study was published in the New England Journal of Medicine and in 2019 an article in the Journal of Urology on the cost-effectiveness in terms of both money and quality of life of the standard prostate cancer treatments: active surveillance, radical prostatectomy, or radiation therapy. Survival was not statistically different among the groups. But disease progression and metastases developed more in the active surveillance group than in other groups after a number of years.
Everything was pretty much the same for six years. But after that, radical prostatectomy and radiation therapy became more cost-effective than active surveillance. Researchers thought it was probably because of the lower metastatic rate for radiation therapy, the cost of repeated biopsies for active surveillance, and the increasing number of active surveillance patients who needed radical treatment over time.
The conclusions are that more aggressive prostate cancers should be treated, and less aggressive ones, if they belong to “good candidates,” should be observed.
The Mediterranean diet
A 2021 study in Cancer showed that the Mediterranean diet is associated with a lower risk of disease progression for men on active surveillance. Remember, if you’re on active surveillance, your cancer is confined to the prostate, your tumor is small and slow-growing, and you have no symptoms. The Mediterranean diet is also associated, in prior reports, with reduced side effects and death from cancer.
Yes, active surveillance is a valid treatment. Your multidisciplinary team can help you make the decision about your path forward. At this point, you and they begin a journey that fits the state of your cancer, your current health, and your treatment goals.