PROSTATE CANCER - Expectant management (watchful waiting) and active surveillance for prostate cancer

Expectant management (watchful waiting) and active surveillance for prostate cancer

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) may never need treatment for their prostate cancer. Instead, their doctors may recommend approaches known as expectant management, watchful waiting, or active surveillance.

Some doctors use these terms to mean the same thing. For other doctors the terms active surveillance and watchful waiting mean something slightly different:

Active surveillance is often used to mean monitoring the cancer closely with prostate-specific antigen (PSA) blood tests, digital rectal exams (DREs), and ultrasounds at regular intervals to see if the cancer is growing. Prostate biopsies may be done as well to see if the cancer is becoming more aggressive. If there is a change in your test results, your doctor would then talk to you about treatment options.

Watchful waiting is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man's symptoms to decide if treatment is needed.

Not all doctors agree with these definitions or use them exactly this way. In fact, some doctors prefer to no longer use the term watchful waiting. They feel it implies that nothing is being done, when in fact a man is still being closely monitored. No matter which term your doctor may use, it is very important to understand exactly what he or she means when they refer to it.

With active surveillance, your cancer will be carefully monitored. Usually this approach includes a doctor visit with a PSA blood test and DRE about every 3 to 6 months. Transrectal ultrasound-guided prostate biopsies may be done every year as well.

Treatment can be started if the cancer seems to be growing or getting worse, based on a rising PSA level or a change in the DRE, ultrasound findings, or biopsy results. On biopsies, an increase in the Gleason score or extent of tumor (based on the number of biopsy samples containing tumor) are both signals to start treatment (usually surgery orradiation therapy).

Active surveillance allows the patient to be observed for a time, only treating those men whose cancer grows, and so have a serious form of the cancer. This lets men with a less serious cancer avoid the side effects of a treatment that might not have helped them live longer. A possible downside of this approach is that there's a chance it could allow the cancer to spread. This could limit your treatment options, and could possibly affect the chance to cure the cancer.

An approach such as this may be recommended if your cancer is not causing any symptoms, is expected to grow slowly (based on Gleason score), and is small and contained within the prostate. This type of approach is not likely to be a good option if you have a fast-growing cancer (for example, a high Gleason score) or if the cancer is likely to have spread outside the prostate (based on PSA levels). Men who are young and healthy are less likely to be offered active surveillance, out of concern that the cancer will become a problem over the next 20 or 30 years.

Active surveillance is a reasonable option for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments in order to try to remove or destroy the cancer.

Not all experts agree how often testing should be done during active surveillance. There is also debate about when is the best time to start treatment if things change.

There have been a few randomized studies comparing watchful waiting (where men were only treated if they developed symptoms from their cancer) and surgery for early stage prostate cancer. In one study, where few of the patients had very early (T1) cancers, the men who had surgery lived longer. In the other, where about half of the men had very early cancers, there was no real survival advantage for treatment with surgery.

So far there are no randomized studies comparing active surveillance to treatments such as surgery or radiation therapy. Some early studies of active surveillance (in men who are good candidates) have shown that only about a quarter of the men need to go on to definitive treatment with radiation or surgery.