Watchful waiting and Active surveillance

Prostate cancer is one of the only cancers for which not treating is a valid option.  You can choose to wait and watch.  This is because the cancer is usually slow growing, and it is often found at a very early stage.  Many men with prostate cancer will die from other unrelated causes before the prostate cancer has a chance to spread or cause symptoms.  Watchful waiting means to not treat the cancer, but to just monitor it, and possibly have treatment at a later date if it is growing.

The first dilemma of watchful waiting is that you have to hope you die of something else first before the prostate cancer causes troubles.  This can cause a lot of anxiety in men, knowing that there is an untreated cancer in their body.  It is like a ticking time bomb, albeit a very slow one, but a constant reminder of our own mortality.

The second dilemma is that the earlier a cancer is treated the more curable it is.  If you wait until the cancer has grown before you start treatment, it may be less curable.  Many men on watchful waiting do end up eventually having treatment, because they either become very anxious about the process, or because a repeat biopsy or repeat PSA measurement shows that the cancer is growing.

Guidelines for who may be able to go on watchful waiting are:

• PSA less than 10
• Gleason score of 6 or less
• Cancer found in up to one third of the biopsy cores, and no single core has 50% cancer involvement or greater.
• Men psychologically able to deal with having an untreated cancer, and willing and able to undergo the future re-testing.

Age is also certainly a variable here.  Someone who is in their 50’s will most likely need to have the prostate cancer treated at some point in their lifetime.  Someone is in his 70’s who has other health problems probably will not.   For younger patients or for those men with more aggressive prostate cancers, treatment is usually recommended.  If you are considering active surveillance, your urologist may recommend a second extensive “mapping template” biopsy, to get a better idea of whether any higher Gleason score cancer is lurking in the prostate.

Watchful waiting comes in two flavors: passive and active.  They are very different.

Passive watchful waiting is usually simply known as watchful waiting.  There is not much follow-up testing that occurs, and there are no real contingency plans.  This may be a valid approach for elderly men who never should have had prostate cancer screening or a biopsy done in the first place, but did, and were discovered to have an early prostate cancer.  The doctors are basically saying, “we are going to pretend this diagnosis never occurred”.   Radiation and surgery are not in the future plans.  If symptoms of urine blockage or painful cancer in the bone ever develop, then hormonal therapy is typically prescribed at that point.

Active watchful waiting is usually known as active surveillance. It involves a methodical approach.

1. A schedule of re-testing.  The PSA is checked every 3 months for the first 2 years, then every 3 – 6 months after that.  The rectal exam (DRE) or prostate ultrasound is repeated every 6 months.  The prostate biopsy is repeated every 1 – 2 years.
2. There are setpoints at which treatment is recommended based on retesting.  You may decide with your doctor that if the PSA hits a value like 10, or if a repeat biopsy shows a higher Gleason score or more cores positive that you will embark on treatment then.

In addition, during the period that you are on active surveillance it may be beneficial to work on a healthy diet, exercise, and lifestyle factors to try to maximize health.  Dr. Ornish conducted a study in San Francisco implementing diet and lifestyle changes in men on watchful waiting and he was able to stabilize the PSA.

Active surveillance is not for everyone.  But it can be a good option for a motivated patient with early stage prostate cancer, especially when used as a wake up call to work on all aspects of health.