Prostate Cancer: When to Treat Versus When to Watch

Because certain prostate cancers grow very slowly, your doctor might determine that it’s not likely to present a significant threat to you. This is particularly true if a prostate cancer is localized, meaning it hasn’t spread beyond the prostate.

If that’s the case, you and your doctor can discuss getting regularly tested instead of undergoing treatment right away. We call this approach active surveillance, or expectant management with curative intent. By not rushing into treatment for a cancer that may not cause you any harm, this approach helps many men avoid treatment-related side effects. At Johns Hopkins, this approach has been used for over 25 years for appropriately selected patients.

Active surveillance, or active monitoring, means your doctor will monitor you closely, watching to see how the cancer progresses, if at all. This is primarily for cancers that doctors classify as:

• Slow-growing
• Very low risk for causing symptoms
• Extremely low risk of metastasizing (spreading to other organs)

Prostate Cancer Treatment: What Active Surveillance Looks Like

To monitor a low-risk prostate cancer, someone on active surveillance could undergo several tests:

• PSA test : Twice a year. This blood test, commonly used to screen for prostate cancer, measures how much prostate-specific antigen (PSA) is in your blood.
• Digital rectal exam: Once a year (A digital rectal exam is done with the doctor’s finger to palpate the prostate for any change).
• Prostate MRI scan : Every 2 to 3 years (MRI is used to detect and then monitor cancer growth during active surveillance and also to help target follow-up biopsies).
• Biopsy: Every 1 to 5 years (depending on results of the digital rectal exam and MRI)

Prostate Cancer Treatment: When Monitoring May Be Enough

Your urologist will consider many factors before deciding whether this approach is right for you. By putting together the digital rectal exam, PSA, MRI and biopsy results, your doctor will determine if you remain at low risk for progression of prostate cancer.

• Physical characteristics: Another way your doctor will assess prostate cancer is through a rectal exam. If he or she can’t feel a hard nodule (a sign of cancer) for example, then the clinical stage is low. Surveillance may be an option if the other results indicate a lower risk.
• PSA results: A PSA test is the standard way to assess prostate cancer risk. PSA can fluctuate but typically increases slowly with age, but rapid increases may mean that it is time to get more tests or a biopsy. Your Urology provider may instead run a PHI test, which is more specific for changes in the cancer and also results in a PSA level that can be put into context with your prior PSA levels. PSA test results along with information about prostate size (determined by MRI or ultrasound) provide us with a value called PSA density. A PSA density less than 0.1 is very favorable, and PSA density less than 0.15 is also associated with a low progression risk, while a PSA density of 0.2 or greater raises a concern for a cancer that may need treatment.
• MRI results: We compare new MRIs to prior MRIs to look for change, and also characterize the appearance of any abnormal area using a scoring system called PI-RADS. Changes on MRI and advancing PI-RADS scores can be cause for concern and may lead to another biopsy.
• Biopsy results: A prostate biopsy (removing tissue samples from the prostate) is the only definite way to diagnose prostate cancer today. A confirmatory biopsy a year after the initial diagnosis is typically recommended, and your doctor may request an MRI before one of these sessions as well. Subsequent biopsies are generally recommended at increasing time intervals.
• Gleason score: This is a score that helps the doctor determine which prostate cancers may be suitable for active surveillance. Determined at biopsy, the Gleason score grades how abnormal prostate cancer cells appear and how likely those cells are to spread (metastasize). Gleason scores range from 6 to 10. Cancers rated Gleason 6 (3+3) are considered lower risk and may be appropriate for active surveillance. Some cancers with a score of 7 (3+4) may be approached with active surveillance, but with closer monitoring. Cancers with Gleason scores of 4+3 =7, or 8 or higher are almost always treated. 

Pavlovich says, “At Johns Hopkins we have been monitoring men with prostate cancer on active surveillance since 1995 and have enrolled more than 2,000 men since then.

“With proper patient selection and a healthy relationship between patient and provider, where the surveillance plan is outlined and followed, we have shown that this approach is extremely safe. We can avoid or defer curative treatment for virtually all men in the program without significant risk of cancer progression.

“While no approach to cancer is 100% safe, we are trying very hard to continue to treat only men with aggressive cancers, since curative treatments can have significant side effects”. Remember to ask your provider whether there are any new treatment options available to you at your annual visit – the field is constantly changing and technology is making surveillance safer and more tailored to the individual and their unique situation.