Active Surveillance with High Resolution Color-Doppler Transrectal Ultrasound Monitoring
It is well recognized that we may be over-detecting and over-treating prostate cancer. Studies have reported an over detection rate of 48%. This is due to increased awareness of prostate cancer with easy access to PSA testing and ultrasound guided transrectal biopsies.
Despite strong evidence that immediate treatment is often not beneficial, 75% of men 75 years or older with low risk disease undergo local treatment rather than pursuing an Active Surveillance program. Data shows that 94% of men with low-risk prostate cancer received radical treatment. Overall, the lifetime risk of dying from prostate cancer remains less than 3%.
Watchful Waiting is a widely accepted treatment for older men with prostate cancer. Since prostate cancer typically involves a slow-growing tumor, several decades often pass before it becomes a life-threatening disease. Traditionally, Watchful Waiting means not considering any local treatment such as surgery or radiation and initiating androgen deprivation therapy when clinical symptoms develop.
The concept of Active Surveillance is different from that of Watchful Waiting. The strategy of Active Surveillance is not to forgo radical local treatment altogether. Rather it is to delay the treatment as long as possible and to offer treatment only when disease progression is confirmed during close clinical observation.
Most importantly, one should not lose the window of opportunity for successful local therapy. The selection criteria for Active Surveillance as applied to low risk disease continues to evolve. The clinicaln parameters used to predict cancer aggressiveness are the PSA level, Gleason score, and tumor stage.
Favorable risk (low risk) prostate cancer is characterized as a PSA of 10 or less, a Gleason score of 6 or less, and T1c-T2a disease. For patients over age 70, the criteria are typically somewhat relaxed. Some practitioners have allowed patients with a Gleason grade up to 7 (3+4) and a PSA up to 15 to have Active Surveillance. Factors such as percent of positive tissue cores (fifty percent or more cores positive), or a PSA velocity above 2 ng/year, are signs of a more aggressive disease suggesting the need for a definite treatment rather than Active Surveillance.
With the ability to use state-of-the-art imaging technology, Active Surveillance becomes an even more acceptable path for those meeting the selection criteria. Along with closely monitoring the PSA at regular intervals, we are now able to use the Color-Doppler Ultrasound to visually and objectively monitor any known cancerous areas. These areas can be identified, precisely measured, and documented providing the treatment team with another tool to assess the growth and aggressiveness of the disease. As long as all the measurable data remains stable, the need for a definitive treatment can be delayed.
For more details, please read the following articles by Dr. Duke Bahn.