"The groundwork of all happiness is health." - Leigh Hunt

Active surveillance for prostate cancer is a leap of religion

November 7, 2023 – When Allan Greenberg was diagnosed Prostate cancer In 2012, he decided to take a then-unusual approach to treating the disease.

He did practically nothing.

Instead of treating his prostate cancer radiation or surgery, Greenberg decided lively monitoring to observe the disease. Only when the cancer got worse would he seek treatment.

Now, at age 83, Greenberg's prostate cancer has shown little to no change, and the retired college professor is considering forgoing lively surveillance and treatment entirely for the winter of his life, but has not yet made a call.

“At my age, treatment is the last thing I would consider,” Greenberg said from his home in Vermont. “Although it appears that the situation is getting worse, I am not sure whether I would seek treatment at this time.”

So if treatment is off the table, why trouble with monitoring in any respect?

Active monitoring

That's the query 1000’s of aging men must ask themselves as the probabilities of them dying from a low-quality prostate cancer diagnosis made a decade or more earlier appear slim.

Active surveillance for prostate cancer replaces radiation treatment or a Prostatectomy with regular monitoring. Monitoring may include blood tests for prostate-specific antigen (PSA), MRIs, and biopsies.

Active surveillance is meant just for grade 1 or low-risk prostate cancer and for some grade 2 low-risk prostate cancer cases.

Prostate cancer ranges from grade group 1 (lowest grade) to grade group 5. A Gleason rating is the normal system for classifying the severity of cancer. The cells are rated based on various aspects on a scale of 1 to five. A pathologist assigns a Gleason grade to probably the most predominant pattern in a biopsy and a second Gleason grade to the second commonest pattern. For example, a Gleason rating of three+3 is taken into account a foul grade.

“There is a wealth of literature that shows that grade 1 prostate cancer in particular is very, very different from other cancers,” he said Kevin Ginsburg, MD, assistant professor of urology at Wayne State University School of Medicine in Detroit. “As a result, the harm of treatment often very often outweighs the benefit.”

Ginsburg, who can be co-director of the prostate program Michigan Urologic Surgery Improvement Collaborativesays the downsides of lively surveillance — spreading the cancer and killing the patient — are small. A study from Johns Hopkins A study of a gaggle of greater than 1,800 men found that “the risk of cancer death or metastasis in long-term follow-up was less than 1%.”

“I firmly believe that with good, high-quality active surveillance, the likelihood of missing the ability to treat and cure someone when that point comes is very, very, very low,” Ginsberg said.

The advantages of lively surveillance include avoiding debilitating treatments that may leave a patient incontinent or impotent. For many men who select lively surveillance, that is a high quality of life issue. Prostate cancer progresses slowly and is subsequently suitable for surveillance.

Cancer in lower case

Laurence Klotz, MD, a urologist on the University of Toronto, named and helped establish lively surveillance greater than 30 years ago. At that point, 95% of men with mild prostate cancer were treated.

Today, lively surveillance is the popular option for low-risk cancers. The Number of Men With Prostate Cancer Who Elected Active Surveillance has doubled nationwide between 2014 and 2021, with about 60% of men eligible for lively surveillance selecting it. That's a rise from 27% in 2014 and 10% in 2010.

A recent study from Italy found that 83% of men preferred lively surveillance to immediate treatment. Last 12 months, the American Urological Association and the American Society for Radiation Oncology reiterated their recommendation for active surveillance.

Klotz sees advanced technology as a “disease of modern medicine.” More sophisticated diagnostic tools can result in overdiagnosis – and subsequently overtreatment – ​​in any specialty, including prostate cancer.

“We would be better off with the diagnostic strategy if this were not detected at all,” Klotz said. “The majority of prostate cancers pose no threat to the patient.”

Michael LeapmanMD, associate professor of urology at Yale School of Medicine in New Haven, CT, notes that PSA blood tests are effective at detecting early-stage prostate cancer but usually are not pretty much as good at distinguishing between aggressive and fewer worrisome tumors .

“The active surveillance movement actually comes from the recognition that there are a large number of prostate cancers that are classified as prostate cancer but are indolent and unlikely to cause a problem in a man's life,” Leapman said.

Some experts are even urging To stop referring to early, low-grade prostate tumors as “cancer.”

Daniel Lewis, MD, an internal medicine physician at Facey Medical Group in Los Angeles, said a patient's decision to undergo lively surveillance is influenced by their risk tolerance. When considered one of his patients is diagnosed with prostate cancer and opts for lively surveillance, he asks them in the event that they would love to get a second opinion. Lewis, also chair of the Black Physicians Council at Facey, often sees relieved faces from patients who don't need treatment.

Dying with – not from – prostate cancer

Participation in and discontinuation of lively surveillance are individual decisions for patients. Factors to contemplate include quality of life, age, general health and life expectancy.

Some men reduce their lively monitoring later in life and opt for less than an occasional PSA test. Others stop monitoring altogether because they’ve lived long lives and have chosen not to speculate time in monitoring something that’s unlikely to be the reason for their death at this point. While some men proceed surveillance for safety reasons, others stop because, well, why not?

Ira Kaget was diagnosed with low-grade prostate cancer in March 2009 on the age of 66. After the initial shock, Kaget, now 80, researched the subject and spoke to experts. Because of his Gleason rating of just 3+3 and the horror stories he heard from men who regretted the treatment, he opted for lively surveillance. He receives an MRI-guided targeted biopsy every two years and regular PSA testing.

Now, almost 15 years after his initial diagnosis and his condition little modified, Kaget has no plans to vary course.

“I plan to continue with this, continue monitoring and am committed to working on my case,” Kaget said. “The goal is to die with it and not because of it.”