Active surveillance for prostate cancer at Penn State Health

Each year in the U.S., a quarter of a million men receive a prostate cancer diagnosis. Despite the seriousness of this number, the mortality figures are far smaller: fewer than 35,000 prostate cancer deaths occur each year. More than 3 million prostate cancer survivors live in the U.S. today. Oncologists at Penn State Cancer Institute (PSCI) use these facts to shape the way they approach care for prostate cancer patients, frequently adopting an active surveillance approach for patients who meet the appropriate criteria. In this approach, physicians identify men whose cancer is unlikely to spread, testing frequently to assess the cancer’s status as time passes. Meanwhile, they do not otherwise treat the cancer.

“We now understand from historical data that traditionally, we had been over-treating prostate cancer,” says Matthew Kaag, MD, associate professor of urology at Penn State College of Medicine and urologist at Penn State Cancer Institute. “All treatments for prostate cancer have side effects, and many patients will survive perfectly well without any treatment. Active surveillance allows men with low-risk disease to avoid the downside of active treatment for at least a period of time.”

Physicians at PSCI follow the guidelines and recommendations of regulatory groups, including the National Comprehensive Cancer Network and the American Urological Association (AUA) when determining which patients are good candidates for active surveillance.

“There’s a lot of anxiety surrounding a cancer diagnosis,” says Dr. Kaag, noting that some patients’ fears surrounding cancer rule them out as candidates for active surveillance. “Our job as urologic oncologists is to lay out all the patient’s treatment options, which include radiation, surgery and active surveillance, and talk about the pros and cons of each. I try to get a feel for my patients’ anxiety levels and what their tolerance might be for the side effects of treatment, as opposed to leaving the cancer untreated but carefully observed.”

Dr. Kaag also encourages clinicians to follow the current guidelines for prostate cancer screening, which have undergone several changes in the last decade.

“We’ve narrowed down who should be screened and who shouldn’t,” Dr. Kaag says. “And because there is also a push for active surveillance, there’s no reason not to discuss screening with patients who meet the criteria. In the end, the choice of whether to screen comes down to shared decision-making between the doctor and the patient.”

CLOSE OBSERVATION

Active surveillance involves a regimen of scheduled testing. This includes a PSA blood test and a digital rectal exam every three to six months, extended to once a year in select patients with stable results. Urologic oncologists at PSCI also often perform a confirmatory MRI fusion biopsy, in which an MRI of the prostate is fused with an ultrasound image and used to guide the transrectal biopsy. Repeat prostate biopsies, with or without MRI fusion, are repeated every one to three years.

“We want to catch any disease progression immediately,” says Dr. Kaag, who estimates about 30% of his prostate cancer patients are currently undergoing active surveillance. “Early detection of progressing disease allows us to transition patients off active surveillance and into treatment. Outcomes in properly selected patients who go through appropriate active surveillance protocols are excellent, equivalent to patients who have surgery or radiation but without the side effects.”

This article first appeared in Central Pennsylvania MD News September 28, 2021.