Active surveillance for prostate cancer

Active surveillance is advised in men with low-risk of progression of prostate cancer to avoid any side-effects from the treatment. Prostate cancer usually grows quite slowly. Additionally, in many cases, the men might not even have any signs and symptoms of the cancer, when the disease is diagnosed. Sometimes, even before the prostate cancer increases in size and starts spreading, men have already outlive their normal lifetime.

Active surveillance for prostate cancer might be recommended for multiple reasons as displayed below:

• Small sized cancer – In case the cancer size is small and is restricted to one part of the prostate gland in early diagnosis, active surveillance is advised. No treatment is advised in patients with small-sized prostate cancer as to avoid any side-effects from the treatment.
• Other severe diseases – In case the patient is suffering from some other life threatening diseases as well, which are reducing the life expectancy of the patient, then the doctors suggest going for active surveillance for prostate cancer. Some of the other severe diseases for which doctor suggest active surveillance include stroke, diabetes, heart diseases or any other cancers in the body.
• Low Gleason score – Gleason score is a very common type of grading system for prostate cancer. In this system, the pathologist carefully examines the affected cells due to cancer and their arrangement in the prostate gland. Accordingly, a suitable score for cancer is assigned on the scale of 3 to 5.

Hence, if the patient’s Gleason score is too low i.e. 5 and lower, it means that the cancer is progressing very slowly (indolent form) and is not aggressive in nature. In such cases the doctors recommend Active surveillance for patients. However, if the score is 7 or above the cancer is aggressive type and would require treatment. Patients having a Gleason score of 6 are advised regular follow-ups and close monitoring, by the doctor, with no treatment if the score doesn’t worsen.

There are some risks associated with the active surveillance of prostate cancer as highlighted below.

• Increased cancer growth – Prostate cancer may grow in size and start spreading while the waiting period is still going on (watchful waiting). In such cases, the opportunity for effective and early treatment may be lost.
• Anxiety – Feeling of anxiety in patients may sometimes lead to an uncertainty of the cancer status.
• Fewer treatment options – If the prostate cancer becomes aggressive and starts growing rapidly, then the treatment options left are extreme with higher side effects.

Various procedures to test for Prostate cancer and their details (Phase of Active surveillance)

During the active surveillance phase, the patient will have to come to the doctor for regular follow-ups and monitoring for prostate cancer, every few months. During these follow-ups, the doctor may advise some tests and procedures to be done, as mentioned below.

• Prostate-specific antigen (PSA) blood test – In this test the total amount of PSA is measured in the blood of the patient. An increased amount of PSA in the blood implies the cancerous growth in the prostate.
• Digital rectal exam – In the digital rectal exam the doctor examines the prostate gland by gently inserting a lubricated gloved finger into the rectum of the patient. This helps the doctor to feel the surface of the prostate from inside and hence, detect the progression of cancerous growth.
• Collecting prostate cells or prostate biopsy – Prostate biopsy involves taking the sample of cells from the patient's prostate gland. This is usually advised one year after the active surveillance starts. The prostate biopsy is generally repeated after an year to examine the cancer progression and to recheck the Gleason score in order to reconfirm if the cancer is still small and non-aggressive.
• Ultrasound scan - If the doctor is not sure about the other tests, then a transrectal ultrasound may be advised to get a confirmed diagnosis of the prostate cancer. A small cigar-shaped probe is inserted into the patient's rectum. This probe transmits sound waves and the reflections captured form an image of the inner part of the prostate gland on the monitor of the radiologist. These images formed are very clear and extensive in nature. This ultrasound scan helps the doctor to clearly examine the details of the prostate gland and check for the progression of cancer.

The patients who are advised for watchful waiting or Active surveillance for prostate cancer are recommended no treatment. No treatment in this stage means no medicines, surgery, or radiations to be performed. The patients in this active surveillance phase are the ones in whom the prostate cancer either does not grow at all or might be growing at a very slow pace. In some cases, the patients might be asked to terminate the period of active surveillance and go for a treatment option. Some scenarios wherein the patients would be advised a treatment are mentioned below.

• Cancer becomes aggressive in nature and starts spreading out from a small area to the rest of the prostate gland rapidly.
• Cancer starts showing worsening signs and symptoms in the patient. Some of the signs and symptoms of prostate cancer are as follows:
• Weak or disruptive urine stream
• Incessant urination throughout the day and night.
• Urine retention or unable to urinate
• Difficulty or discomfort to urinate
• Pain while urinating
• Not able to stand while urination (sitting feels better)
• Uncontrollable urination (not able to control the pressure at all)
• Blood in semen
• Blood in urine

If prostate cancer has spread to other parts of the body it is known as Metastatic prostate cancer, which is also the advanced stage of the cancer. The sign and symptoms of the Metastatic prostate cancer are as mentioned

• Fatigue
• Indefinable weight loss
• Blockage in the lymph nodes leading to swelling in the legs.
• Dull, but slowly getting severe, pain felt in the lower back.
• Increased loss of breath while performing normal routine activities which were easily tolerable before cancer.
• Easy bone fractures or breaking of bones more frequently than expected i.e. even due to minor trauma.

It is always advised to get prostate cancer treated if the cancer is growing rapidly. If the cancer is diagnosed and treated at an early stage, the patients are usually benefitted. However, if the cancer reaches the Metastatic phase, then the prostate cancer can be only treated and not cured.

Q1. What are the risk factors that cause prostate cancer?

A1. Risk factors which may lead to prostate cancer are as mentioned.

• Age – Approximately 60% cases with prostate cancer are men with the age of 65 years and above. The men in age range less than 40 years are less likely to have prostate cancer.
• Family History – The chances of getting prostate cancer are more if there is any past family history. If the family member was young when the cancer was detected, then the chances of getting prostate cancer in the relative male family member are higher.
• Genetic factors – There is part of DNA in men, wherein if the mutations happen (BRCA2 gene), then the chances of getting any cancer including prostate cancer are very high. The similar mutation in the DNA of a female family member increases the chances of getting ovarian or breast cancer. There are some other inherited genes whose mutations can cause prostate cancer including HoxB13, BRCA 1, HPC1, RNASEL, and DNA mismatch genes.
• Chronic smoking – Increased risk of prostate cancer in chronic smokers.
• STDs i.e. Sexually Transmitted Diseases – People who have STD are at risk of developing prostate cancer.
• Other factors – Unhealthy diets like fatty food, low intake of vegetables and fruits, and red meat lead to an increased risk of prostate cancer. Excessive weight issues or obesity, high calcium intake and dairy products are also amongst the contributing factors for prostate cancer.

Q2. How reliable is the Prostate-specific antigen test (PSA test) for identifying prostate cancer?

A2. Though, PSA test helps in the early detection of prostate cancer but an increased amount of PSA in the blood does not necessarily mean that the person has prostate cancer. There are some cases such as in the case of patients with benign prostatic hyperplasia (BPH), prostatitis or enlarged prostate gland, wherein increased PSA levels can be observed in the blood of the patients.

Also, the PSA test cannot identify all cancers. Sometimes, the people who even have normal levels of PSA (around 20% cases), actually have prostate cancer which is detected by further testing. In such cases, when the doctor is unsure of the results of the PSA test, some other tests are advised to the patient for a confirmed diagnosis.