The process of Active Surveillance, the way we practice in Marina del Rey, is to perform a PSA blood test every three months and plot these results on a graph, to see if there is any continuous rise that would be suspicious. More importantly, a regular scan of the prostate gland with Color Doppler ultrasound, 3 Tesla multi-parametric MRI, or a combination of the two. These modalities, the scanning and the PSA testing, constitute the methods for keeping an eye or performing Active Surveillance, in a man with low-risk prostate cancer.
What would lead someone to go off Active Surveillance-what are we looking for? The answer to that is over time, if an abnormality that’s being tracked on scanning, shows sequential enlargement, or perhaps increasing vascularity, that could be a sign that the tumor is growing or changing – a targeted biopsy would be performed at that point to check the grade of the disease.
Alternatively, there is a possibility, since these men have normal prostate glands, to develop a new prostate cancer. Prostate cancer is very common, even in the same man. By the time us guys die, most of us have three to five prostate cancers lurking in our prostates, mostly low grade, not causing any harm. But if one of them is a higher grade, then of course, that needs to be addressed. Men with low-risk prostate cancer that are getting Active Surveillance, can develop new cancers. I believe this is one of the most important aspects of Active Surveillance, is to watch, not so much for the low-grade cancers which rarely change, but to watch for the possibility of a new higher grade cancer surfacing in another portion of the prostate. So that higher grade tumor would get diagnosed at an earlier stage, when the individual can still be cured.
Some men while they are on Active Surveillance, will have a new abnormality detected or an older abnormality that appears to be growing, and will be recommended to have a targeted biopsy of the abnormality, this will give a Gleason score. Sometimes, the Gleason score will be higher and those individuals will need some form of treatment. The treatment of prostate cancer is quite varied and there are many different options.
Many factors come into play in deciding what kind of treatment is going to be optimal – a patient’s age, the grade of the tumor, how high the PSA is, how fast it’s growing and the preferences of each individual. Different treatments have different risks. We have a long list of new treatment options now including focal therapy, hormone therapy, surgery, radiation of many different forms, cryotherapy, on so on. It’s a large list of opportunities that people have for treating prostate cancer, if and when the disease looks serious enough to actually require treatment.