When Is Active Surveillance the Right Choice for Prostate Cancer?

November 15, 2023

A cancer diagnosis brings with it many questions: How advanced is the cancer? Has it spread? How will it be treated? Prostate cancer is no exception. Many men may feel they need to take immediate action after a diagnosis. However, aggressive treatment is not always the best choice.

“When prostate cancer is found early, there are many effective treatment options that may be offered,” says Jonathan Shoag, MD, urologic oncology specialist at University Hospitals. “However, based on several considerations, one option might be no treatment at all – at least not right away. Instead, we might decide to monitor if and how the cancer progresses over time. This is called active surveillance.”

What is Active Surveillance?

For most types of cancer, immediate treatment is recommended. However, many prostate cancers are slow growing and less aggressive than other forms of the disease. Often diagnosed at older ages, many men can live with a slow-growing prostate cancer that never causes any symptoms, harm or lifestyle limitations.

Active surveillance may be an option for men with prostate cancer that isn’t aggressive and hasn’t spread. Instead of treatment, the tumor is regularly monitored for signs that it is changing or growing with blood tests to measure levels of prostate specific antigen (PSA), a protein that is made by the prostate gland. MRI scans and biopsies may also be part of active surveillance.

Developing a Personalized Treatment Plan

If diagnostic tests suggest that the cancer is changing, your doctor may start discussing a treatment plan. “At University Hospitals, we refer to these conversations as shared decision-making,” says Dr. Shoag. “It provides a one-on-one opportunity to discuss the available treatment options, their potential side effects, and what to expect throughout treatment and recovery. Perhaps most importantly, each patient is encouraged to share their goals and lifestyle expectations as they consider moving ahead with treatment.”

“It’s all very personalized,” says Dr. Shoag. “Every cancer, and every patient, is different. However, our primary goal is always to preserve quality of life and minimize treatment side effects, which may include sexual and urinary dysfunction, hair loss, nausea and fatigue, depending on the type of treatment received.”

Prostate Cancer Treatments

Recommended treatments may include one or more of the following:

Medical Therapy. The most common type of medical therapy is hormone therapy, a treatment that reduces testosterone which prostate cancers need to survive. This can be given orally or as an injection and is often given in conjunction with radiotherapy for certain cancers.

Radiation Therapy. The delivery of high doses of radiation helps to slow tumor growth and eventually kill cancer cells. The number of treatments is different for every patient. “At UH, most of our patients undergo stereotactic body radiation therapy (SBRT), a precisely targeted therapy that requires just five treatments,” says Dr. Shoag.

Surgery. Surgical removal of the prostate gland may be a treatment option if the cancer has not spread beyond the prostate. The operation, called a radical prostatectomy, removes the entire prostate gland and some of the surrounding tissues, including the seminal vesicles. Nearby lymph nodes may be removed during surgery to confirm the cancer has not spread.

This surgery is typically done robotically through small incisions in the abdomen, with minimal post-operative pain. It can be done as an outpatient procedure or with an overnight stay in the hospital. “There have been some technical modifications in recent years, such as the use of the hood technique or pelvic-fascia sparing, which we use to substantially minimize the side effects of prostatectomy,” says Dr. Shoag.

Beware of Experimental Treatments

New ways to prevent and treat prostate cancer are always being studied. Ask your doctor if participation in a clinical trial might be an option for you. Patients can enter clinical trials before, during or after starting cancer treatment.

But Dr. Shoag cautions patients to beware of experimental treatments that aren’t part of clinical trials. One example is focal therapy. “Unfortunately, this modality is being offered at other institutions outside of clinical trials, which goes against national guidelines and poses a significant risk to patients,” says Dr. Shoag. “The vast majority of patients who get experimental treatments will have side effects from the treatment and still have cancer afterwards. Many of these men will need additional treatment that wouldn’t have been necessary otherwise.”