Active surveillance for prostate cancer an imperfect science, urologists say

Urologists share when they offered surveillance, what protocol they used, and how patients responded to this alternative to immediate treatment for low-risk prostate cancer.

Problems cited by the panel included the lack of a consistent protocol for active surveillance and what criteria should be used to determine when treatment might ultimately be needed among closely monitored men.

"Nowadays, we've been screening for prostate cancer so long, we're finding cancers earlier, so more patients are candidates for active surveillance."

Dr. Hatcher says the suggestion gets mixed reactions from patients.

"Patients like the idea of keeping an eye on the cancer, but they also get very nervous about having a cancer within them, particularly one associated with PSA growth," Dr. Hatcher said. "So I help patients weigh their own morbidity from cancer and their morbidity from other medical conditions, then decide whether the morbidity of treatment is less than, or greater than, their perceived morbidity from their other illnesses and from prostate cancer combined."

In Honolulu, Garry Peers, MD, on the clinical faculty of the University of Hawaii, also offers active surveillance as an option for certain men diagnosed with prostate cancer.

"The short answer is yes, I offer it. The long answer is that it's not commonly chosen by the individual," Dr. Peers said. "We offer it to the appropriate men, but the repeated biopsies and uncertainty make it an uncommon choice for the individual."

A practitioner for 15 years, Dr. Peers divides active surveillance candidates into three categories.

"The more controversial situations would be the younger man in his 50s and early 60s, who has very small-volume, one or two cores of grade 6 prostate cancer, and a respectable PSA. This is the patient who has the hardest time choosing surveillance.

"The other group is the 80-year-old whose numbers can be significantly higher, where you are still looking for clinical progression to the point that he would initiate some kind of palliative treatment. That would be considered active surveillance on the opposite extreme.

"The trickiest age group is the healthy 70-plus man who feels he is entitled to be treated like a 50-year-old and is not pleased with the concept he won't live long enough that the cancer will hurt him. That's a delicate discussion."