Prostate Cancer Active Surveillance
Sep 16, 2020 Cedars-Sinai Staff
Charles Trevino was diagnosed with prostate cancer eight years ago. Back then, doctors didn't take a wait-and-see approach. They suggested surgery and radiation in almost all cases, even though only 15% of patients die of the disease.
Instead of rushing into surgery and radiation, Charles wanted to explore options. At Cedars-Sinai, he found them.
Diagnosed with prostate cancer eight years ago, Charles Trevino was among the first wave of patients to utilize active surveillance before rushing into surgery.
A team of Cedars-Sinai specialists had a proven track record with a newer approach called active surveillance. Since then, studies have shown that aggressive treatment—such as surgery, radiation and hormone therapy—is not only unnecessary for low-risk prostate tumors but can actually be harmful.
Charles was among the first wave of patients for active surveillance. In just a few years, it's become standard protocol. But what is the active surveillance approach? And what happens when you're diagnosed with prostate cancer?
Most prostate tumors are discovered during a rectal exam or through a blood test If the results indicate a problem, doctors may advise a biopsy and an MRI.
Most prostate tumors are discovered during a rectal exam or through a blood test. For men whose results indicate a problem, doctors may advise a biopsy as well as an MRI.
The biopsy tells doctors how aggressive the tumor is based on the so-called Gleason score: The higher the score, the more serious the tumor.
"We're hoping for a score below seven," says Dr. Stephen Freedland, professor of surgery and director of the Center for Integrated Research in Cancer and Lifestyle at Cedars-Sinai. "If we get it—and we do about half the time—we can give the patient the good news: Active surveillance works."
How does active surveillance work?
Active surveillance involves closely tracking the tumor using both cutting-edge technology such as MRI, old-fashioned tests such as rectal exams and blood tests such as the prostate specific antigen (PSA) test.
For men with a low-grade prostate tumor, Dr. Freedland usually starts with a repeat blood test, biopsy and MRI at the one-year mark. If the tumor can't be detected anymore, there's no need for another biopsy or MRI for another four years, though the patient still needs regular exams and blood tests.
Advances in MRI mean we can track a tumor's size, location and growth with greater precision. Active surveillance involves very little risk because we monitor the patient so closely.
If Dr. Freedland finds any bit of tumor remaining, the biopsy should be done every two to three years. If the tumor is the same size, or growing, he'll suggest treatment or annual biopsies, depending on the situation.
"Advances in MRI mean we can track a tumor's size, location and growth with greater precision," he says. "Active surveillance involves very little risk because we monitor the patient so closely."
In the past, Dr. Freedland explains, many patients had surgery, radiation or hormone treatments they didn't really need. They survived their cancer but had lasting side effects that reduced their quality of life. Some 20%-30% of active surveillance patients still go on to treatment within a few years, because the cancer got aggressive or the patient doesn't want to keep dealing with the regularly scheduled tests and the lingering "what ifs."
What will I need to do?
For optimal success with active surveillance, patients are also encouraged to maintain a healthy lifestyle because men with prostate cancer are at higher risk of heart disease. Metabolic syndrome, which brings serious risks such as high blood pressure and Type 2 diabetes, is also more common among men with prostate cancer.
"As it turns out, what is heart-healthy is also prostate-cancer healthy," says Dr. Freedland, who helped lead a study that showed weight loss can play a positive role in several ways. Weight loss can reduce the side effects of hormone therapy and may slow the growth of recurrent prostate cancers. Studies are underway to determine if weight loss might prevent a low-grade tumor from becoming aggressive.
For optimal success with active surveillance, patients are also encouraged to maintain a healthy lifestyle because men with prostate cancer are at higher risk of heart disease, high blood pressure and Type 2 diabetes.
Charles Trevino had heard it a thousand times: To be healthier, you need to care about nutrition and exercise. Today, he eats lots of fresh leafy greens, consumes very little red meat and drinks alcohol in moderation. He also takes 3-mile walks several times a week. He lost weight and reduced his waist size from a 40 to a 38. Best of all? His cancer is still under control eight years after diagnosis.
"The tumor never grew or got aggressive," says Charles, who says the whole staff at Cedars-Sinai has been supportive and caring. "Dr. Hyung Kim, the specialist who treated me, made me feel truly cared for and made a difficult time so much easier. I know I can trust him and his team. Active surveillance was the right call. My life is actually better than before I was diagnosed!"