Active surveillance is today’s approach

Dear Dr. Roach: I am 58 years old and have early stage prostate cancer. My PSA is 6.5. How do you know when “wait and see” is the right approach? If I do need treatment, what are your thoughts about high intensity focused ultrasound (HIFU)? — T.B.

“Wait and see” or “watchful waiting” was a strategy discussed in the 1980s. It came from the observation that a lot of prostate cancer behaved very indolently. Since prostate cancer treatment, mostly surgery, risked the significant side effects of incontinence and sexual dysfunction, urologists and oncologists reasoned that observation would cause a lot less harm than surgery.

This has evolved into “active surveillance.” This is appropriate for men whose cancers are low risk or very low risk.

To be in the lowest risk groups, the cancer must be small and contained within the prostate; nonaggressive based on pathology; with few positive “cores” by biopsy; and having a low PSA “density.” If your prostate cancer meets all these criteria, then active surveillance is an excellent option. Some men still choose to have the tumor treated; however, there is little benefit and significant potential for harm for men in this lowest risk group.

The strategy of surveillance for men in this group typically includes repeat PSA testing every six months, physical examination every 12 months, and MRI or biopsy within the first year and again every two to four years.

The initial results for high intensity focused ultrasound look promising. However, a joint statement by several groups notes: “clinicians should inform patients considering HIFU that this treatment option lacks robust evidence of efficacy, and that even though HIFU is approved by the FDA for destruction of prostate tissue, it is not approved explicitly for the treatment of prostate cancer.”