Current statistics indicate that approximately one in nine American men will be diagnosed with prostate cancer sometime during their lifetime. Prostate cancer may be asymptomatic, slow growing, and without immediate risk. On the other hand, the cancer may be high grade and aggressive which requires swift treatment. Depending on its grade and progression, prostate cancer can be treated in various ways. For cancer that is low grade and slow growing, watchful waiting and active surveillance may be considered. While these approaches appear to be similar, there are slight differences.
What is watchful waiting and active surveillance?
When recommended, watchful waiting and active surveillance are conservative protocols in which treatment is not yet prescribed. Instead, patients are watched closely through periodic testing. Both options are reasonable based on the grade and stage of cancer, physician monitoring recommendations, and the comfort level of the patient. Neither option will be recommended unless the patient has had a recent prostate biopsy in which tissue has been extracted from a minimum of 12 different sectors of the prostate.
At times, watchful waiting will be suggested for older men who have low volume, low grade cancer in one or two biopsy samples with a Gleason score of six. This is especially true if the patient has other significant medical conditions. Their physician will weigh whether the patient’s health is at further risk from the ordeal of undergoing prostate cancer treatment and its possible side effects. Depending on the patient’s overall health, the physician and patient may choose to focus on their quality of life rather than treatment.
For these men, the cancer is considered so slow growing that the disease is unlikely to progress from low grade to metastatic cancer during their lifetime. These patients will be monitored by their physician, but less often than those under active surveillance. They will continue to have periodic PSA testing, but will not undergo another prostate biopsy. Typically, treatment for these patients will start if they begin exhibiting symptoms associated with prostate cancer.
Similar to watchful waiting, men under active surveillance have low grade (Grade 1 / Gleason 6), low volume cancer. These men may be older adults without significant or chronic health issues. They will be asked to repeat their PSA labs every six months, undergo a digital rectal exam every six to 12 months, and a prostate biopsy annually. The goal is to closely watch the cancer and determine when treatment is necessary. This allows patients to avoid potentially aggressive treatment and possible side effects. Active surveillance may switch to active treatment if a subsequent biopsy indicates that cancer is growing which results in a higher grade cancer with a higher Gleason score.
Risks and benefits
With both watchful waiting and active surveillance, the provider is looking for clinical signs of cancer progression (symptoms). By choosing watchful waiting / active surveillance over immediate treatment, men may benefit by avoiding overtreatment of low grade cancer, potential quality of life issues associated with some procedures (impotence and urinary incontinence), general risks and side effects related to hormone therapy, surgery, chemotherapy or radiation.
Men may hesitate to choose this conservative approach for fear that their cancer may spread. While this is a possibility, watchful waiting or active surveillance would not be recommended for men with a high grade aggressive cancer.
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