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Active surveillance and watchful waiting in management of early stage (localized) prostate cancer

Posted Sep 17 2008 1:31pm

It is important for patients to understand that “watchful waiting” and “active surveillance” really are two appropriate (if similar) forms of management for early stage (localized) prostate cancer.  (You may also come across other terms that mean the same thing, such as “expectant management.”)

For carefully selected men, one or other of these two forms of care may well be the best possible management option. They come with almost no risk of side effects. They avoid all of the socially problematic and expensive aspects of treatment. Finally, if it turns out that the cancer is not particularly active, the result can often be that the patient easily outlives his risk of clinically significant prostate cancer.

What Is “Watchful Waiting?”

In watchful waiting, the doctor will carefully and regularly monitor potential indicators of progression by carrying out  PSA tests and DREs on the patient every 6 months or perhaps every year. Although there is a risk that the cancer will progress, and that it may become clinically active disease which might have been cured if the cancer had been removed when it was first found, on the other hand the quality of the patient’s life has been utterly unaffected by this form of treatment.

Watchful waiting is generally considered appropriate for older patients (of perhaps ≥75 years) who, for one or more  reasons, the physician believes will be better served by avoiding curative treatments such as surgery or radiation. This may be just because of their age, or because of concomitant health problems, or because the patient believes strongly that he would prefer the risk of disease progression to the risks associated with curative treatments.

Watchful waiting may also be appropriate for some men suspected of having localized disease but for whom a biopsy is perhaps an unnecessary intrusion because of their age or health. In other words, even if a biopsy proved to be positive, curative therapy would not be recommended, which makes the biopsy somewhat futile.

For preliminary information about the effectiveness of watchful waiting compared to radical surgery (based on a single, large, randomized, multicenter Scandinavian trial), please  click here.

What is “Active Surveillance?”

Active surveillance is best thought of as a slightly more structured and aggressive form of watchful waiting. There is no formal protocol for active surveillance, but it is customary for physicians to recommend a DRE and a PSA test every 3 or 6 months, depending on the patient’s precise history and clinical condition, and to re-biopsy the patient at least once a year.

Thus, active surveillance for localized prostate cancer is somewhat similar to management for a patient with prostatic intraepithelial neoplasia (PIN), which is believed to be a precursor to early stage prostate cancer (at least in some patients).

Regardless of whether a patient is being managed with active surveillance or watchful waiting, the critical question is always, “What do we do now?” if the patient’s disease does start to clearly progress.

If progression is slow, and the patient is elderly, it may be possible (and even wise) to do nothing for years, and the patient may still never have any clinical symptoms of prostate cancer that are affecting his life. On the other hand, there is evidence that in younger patients, with a life expectancy of 15 years or more, early treatment is beneficial unless there are clear reasons why it would be inappropriate (see article by Johansson et al. ). Watchful waiting and active surveillance are not generally recommended for such patients today.

It is not unknown for men to be on watchful waiting or active surveillance for very long periods of time, with a gradually rising PSA, until they clearly have advanced disease but no sign of metastasis and no bone pain. Even if they progress to the point where they do have bone pain and visible metastasis, they can be started on androgen deprivation therapy of some type at that time. In such cases, they may avoid initial therapy for years and only need hormonal therapy for a relatively short period while still dying of causes other than prostate cancer in their late 80s or early 90s.

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