A New Approach to Low-Risk Prostate Cancer

Ira Lieb, a marketing consultant from the Chicago suburbs, was diagnosed in 2011 at age 71 with prostate cancer, the most common cancer occurring in men after skin cancer. But he has never been treated with surgery or radiation, the most prevalent treatment choices for men diagnosed with this cancer.

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Lieb opted to do nothing other than have his cancer monitored using Prostate Specific Antigen or PSA tests and high-resolution imaging tests known as multiparametric MRIs. If his cancer suddenly or gradually became aggressive, he could still undergo a biopsy and definitive treatment.

The approach is known as “active surveillance” (AS). The number of prostate cancer patients using active surveillance is growing, and researchers are refining protocols for active surveillance.

Back in 2011, Lieb’s PSA  score was rising. The commonly-used PSA blood test measures levels of PSA, a protein, which is a component of semen produced by the gland. Most men without prostate cancer have PSA levels of 2.5 to 4 nanograms per milliliter (ng/mL) of blood. Lieb’s PSA levels had reached 4.5 ng/mL, which raised his doctor's concern about cancer.

So he underwent a biopsy in which a dozen needles were inserted through the rectum into his prostate to extract small bits of tissue. The needles traditionally are inserted in a grid pattern.

Pathologists examine the prostate tissue under the microscope and grade how aggressive any cancer cells look, giving them what's called a Gleason score. The score is based on how much the cancer looks like healthy tissue when viewed under a microscope. The pathologist scores the individual sample from 3 to 5, with a low score looking the most normal and the high score looking the most cancerous. The scores are added together for an overall score between 6 and 10.

Still, most patients like Lieb opt for radical treatments: physicians treating cancer and their patients frequently follow the philosophy of "out, out damned cancer," using surgery, radiation and frequent, aggressive screening.

However, Lieb was concerned about the common side effects of a radical prostatectomy, a surgical operation to remove all or part of the prostate gland, which can include a possibility of impotence, bowel problems and/or urinary incontinence. He found another approach in active surveillance.

Dr. Laurence Klotz, Chief, Division of Urology, Sunnybrook Health Sciences Center at the University of Toronto, pioneered active surveillance in 1997. Klotz said his group concluded the growing popularity of PSA and nerve-sparing surgery to preserve erections was resulting in overtreatment of low-risk patients. The urologists began to monitor these patients with serial PSA tests and biopsies, only treating those patients whose cancers were getting worse.

In the late 1980s and early 1990s, Dr. Gerald Chodak, a University of Chicago urologist and prostate cancer researcher, had campaigned for cautious use of the PSA testing and to avoid using it for mass screening until a benefit was proven. However, it did not happen that way. Instead, widespread use of PSA quickly led to a doubling in the number of diagnosed cases of prostate cancer and overtreatment. Men with low-risk, non-life-threatening cancer often underwent radiation and surgery, which often came with unwanted side effects.

“What you found was increased screening was being done. With increased screening, this whole issue of overdetection was occurring," said Dr. Peter Carroll, the Chair of Urology at the University of California, San Francisco, said. "And overdetection, identifying these low-risk cancers, could be compounded by overtreatment.”

Before active surveillance, men with prostate cancer often were advised to undergo a regular schedule of PSA tests and digital rectal exams in search of irregularities caused by cancer ( lumps, bumps, etc.) every three months. These patients also underwent biopsies annually.

Doctors' attitudes about biopsies have also changed recently, since biopsies pose risks, including bleeding, erectile dysfunction and sepsis that can lead to hospitalization and in extreme cases, death. Though some urologists still recommend annual biopsies for some patients, many are increasing the interval between biopsies.

Carroll said the goal now is to make active surveillance less invasive and to reduce the number of biopsies patients undergo. A two-year interval is common, though some physicians recommend waiting four to five years.

Lieb had a follow-up biopsy in 2013. “It was clean, which is a good indicator, but not a final indicator for no cancer being present,” he said.

Dr. Mark Scholz, a Los Angeles-based medical oncologist, exposed overtreatment by the “prostate cancer industry” in his 2010 book Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency. He said many urologists and radiation oncologists still have financial incentives to treat the disease rather than recommending active surveillance.

However, the active surveillance approach is growing in popularity. Scholz said this year about 35,000 men will chose active surveillance, up from 5,000 a decade ago. He noted that if the cancer “misbehaves" and spreads, there is still plenty of time to intervene with more radical approaches.

An important factor in forgoing biopsy is an imaging technology called a multi-parametric magnetic resonance imaging (mpMRI) scan, which creates more detailed pictures of your prostate than a standard MRI scan. A landmark study in The New England Journal of Medicine in March 2018 found mpMRI more accurate than an biopsy, and Scholz agreed that it is preferable when done at a center with a radiologist who is highly skilled at the technique.

Meanwhile, Lieb — who had an mpMRI in 2017 and had no signs of cancer — is thriving on active surveillance. With no signs of cancer, he has foregone biopsy. Additionally, a recent PSA score was lower than the previous year.

“Do I feel that I don't have prostate cancer? I don't know,” he said. "But if I do, it's a very manageable with active surveillance.”