The most common type of cancer in the United States is prostate cancer, and it is the second-most common cause of cancer deaths in U.S. men behind only lung cancer. According to the National Cancer Institute, about one in five U.S. men will be diagnosed with prostate cancer at some point in their lives.
But, importantly, most men diagnosed with prostate cancer will not die from it. A slow growing cancer, it is often detected by tests before any noticeable symptoms develop, and that means prostate cancer patients have to make a choice, according to Dr. Andrew Harbin of Chesapeake Urology, in Westminster: Opt for radiation therapy or surgery, which can come with side effects, or delay treatment and monitor the cancer for growth over time, a strategy known as active surveillance.
“Over the last 10 years these large studies have come out looking at the mortality between the patients that chose active surveillance and the patients that chose surgery or radiation,” Harbin said. "It was pretty much the same, it wasn’t significantly different. So the odds of dying from prostate cancer whether you opted for surgery, or active surveillance were the same."
But that’s not true for every case of prostate cancer — each diagnosis comes with a different estimation of risk that the cancer will progress, a process that typically begins with screening healthy-seeming men ages 55 to 65, according to Harbin.
“Most prostate cancer these days is caught on a screening PSA test. That’s a blood test ordered usually by primary care physician on an annual basis,” Harbin said. PSA stands for Prostate Specific Antigen, a protein that should remain concentrated in a healthy prostate, he said, but which may begin to leak into the bloodstream if the prostate’s structure is disrupted by cancer.
That test returns a PSA score.
“If it’s less than 10 it’s considered low risk, 10 to 20 is considered intermediate, and greater than 20 is considered high risk," Harbin said. "Generally, if we find an elevated PSA, we may also do a rectal exam. And then the next step is to do a biopsy which confirms the diagnosis."
But a high risk PSA score alone doesn’t translate into a high-risk prostate cancer. The PSA score, the rectal exam results and those of the biopsy are combined to create a Gleason grading system between 6 and 10, according to Harbin. Scores of 6 are considered low risk, scores of 7 are intermediate risk and scores of 8 through 10 are considered high risk for progression and risk of death.
“Active surveillance should be considered in all low-risk patients,” Harbin said. “Anybody with Gleason 6, PSA less than 10 and a normal rectal exam should be considered for active surveillance, and then select intermediate patients as well.”
“The downside to choosing surgery or radiation are fairly significant quality of life effects,” Harbin said. “Both treatments will affect your sexual function and your urinary function.”
Erectile dysfunction can occur, along with urinary incontinence. Side effects that are tolerable when it’s life or death, but not outcomes to rush toward if they won’t improve your odds of beating the cancer.
“When I talk to my patients about this, I tell them if it’s not preventing you from dying of cancer, and it is giving you all of these other side effects, there really is no upside to doing surgery or radiation in low-risk prostate cancer,” Harbin said. While he regularly performs surgeries on high-risk and intermediate-risk prostate cancer patients, he can count the number of low-risk patients on whom he has operated on one hand.
That’s not to say there are not exceptions, however, Harbin said, and it is always up to a patient how they would like to proceed — every treatment option is still a treatment option, even for low-risk prostate cancer patients. And other factors may affect the decision-making process.
Older patients may be much more likely to die from another ailment before their low-risk prostate cancer could really threaten them, Harbin notes, and may choose active surveillance to avoid unnecessary side effects. Younger patients, meanwhile, may simply be too uncomfortable living with a cancer diagnosis for decades and opt to get it removed and over with.
“In early studies, the number one reason to come off active surveillance was actually anxiety, losing that comfort level of living with cancer,” Harbin said. “It’s a long time to live with cancer if you are going to live 40 years because your heart is strong and you’re young.”
That said, evidence suggests active surveillance is always worth consideration in lower-risk prostate cancer patients, according to Harbin, and should be contrasted with a similar strategy that went by a different name, watchful waiting.
“The concept of watchful waiting, it’s you know, that’s kind of a negative ring to it. It sounds like you are doing nothing, while the term active surveillance has ‘active’ in it,” he said. “The real difference is that active surveillance involves repeating the biopsy at least one time in the future, to reconfirm that the cancer has not converted to a more aggressive cancer.”
While there is no official guideline or protocol for active surveillance, Harbin said, it generally means getting a follow-up biopsy once a year and PSA tests paired with rectal exams every six months. This is why studies are showing active surveillance can be as good as active treatments for low-risk prostate cancer, he said, because as soon as the cancer is detected as having become more aggressive, patients switch to surgery or radiation. They avoid unnecessary side effects, acting to remove the cancer when it becomes a greater threat.
And while hearing that you have cancer can still be anxiety causing, Harbin said more and more people are coming to realize there are different strategies available in how you fight back.
“I think the public is now aware that prostate cancer is not the most progressive cancer — there’s a lot of people dying with it rather than from it," Harbin said. "I think people have become a little bit more comfortable with, with the concept of not being overly aggressive with these low risk cancer.”