PSA screening has led to an increased number of patients diagnosed with low volume, potentially insignificant risk prostate cancer and these patients have a low probability of prostate cancer specific death over a 10–15-year period. Therefore, in this sub-group of patient’s active surveillance as initial management would seem appropriate.
Active surveillance is not watchful waiting. Active surveillance implies an initial conservative approach to prostate cancer management, proceeding with definitive curative treatment when patients show signs of progression of prostate cancer during the active surveillance protocol. Active surveillance is usually considered appropriate for patients with low volume Gleason score 3 + 3 = 6 adenocarcinoma, non-palpable cancer on digital rectal examination (or a small nodule, stage T2a malignancy) and a PSA level of < 10.
Some active surveillance protocols also include low volume Gleason score 3 + 4 = 7 malignancy if there is a low volume of Gleason pattern 4 malignancy. Based on the randomised ProtecT study from the UK, the risk of prostate cancer specific mortality on active surveillance protocols is <5% over a 15-year period. However, during this time, 2 out of 3 men will progress and require definitive local treatment, usually with either surgery or radiotherapy. Active surveillance is now the most common initial management plan in Australia for patients with low grade Gleason 3 + 3 = 6 malignancy.
The triggers for intervention include progression to higher volume or higher-grade disease on surveillance biopsy, new suspicious lesions on surveillance prostate MRI or PSMA-PE scans, PSA doubling time < 3 years, or change in patient preference towards definitive treatment. (4)
In contemporary urology, the use of radiology images with prostate MRI scans or PSMA-PET scans during surveillance can detect non-palpable progression within the prostate, giving an early warning to patients that a repeat prostate biopsy is required. In contrast, negative radiology imaging in the presence of stable PSA levels can allow clinicians to decrease the number of prostate biopsies during the active surveillance period, with a low risk of missing clinically significant prostate cancer progression.
The limitations of active surveillance include patient anxiety regarding the potential loss of curability during the active surveillance period. On current data around 1 in 10 men will potentially lose “curability” over a 15-year period with an initial period of active surveillance. This must be balanced against the benefits of surveillance, including avoidance of side effects of treatment such as impotence and incontinence of urine. The role in active surveillance in men under the age of 60 years at the time of diagnosis will become clearer when 20-year data is available.