Active Surveillance for Prostate Cancer: Who Is It Right For?

Andrew Schorr:

Hello and welcome to Patient Power sponsored by the Seattle Cancer Care Alliance.  I'm Andrew Schorr. 

When a man is diagnosed with prostate cancer, there are decisions to be made.  For instance, do you go ahead right away with treatment, or maybe not.  Maybe you have something called active surveillance.  One of the leaders in the field of active surveillance, studying it for many years, is Dr. Daniel Lin.  He is chief of urologic oncology at the University of Washington.  He's also an associate member at the Fred Hutchinson Cancer Research Center, and he sees prostate cancer patients at the Seattle Cancer Care Alliance.  And he joins us now once again on Patient Power.  Dr. Lin, welcome back. 

Dr. Lin:

Well, thank you for having me. 

Andrew Schorr:

Dr. Lin, what is active surveillance, and who is it right for? 

Dr. Lin:

Active surveillance is one of the options in men who are newly diagnosed with prostate cancer and mostly those men that have what we call low?risk prostate cancer.  So these would be men that have a low Gleason grade, usually Gleason 6 or less, and men that have a PSA of less than 10 as well as a normal digital rectal examination.  So we classically consider these as low-risk patients. 

Additionally, we look at the biopsy characteristics, in other words, how many of the pieces of prostate tissue that are taken out have prostate cancer, and we usually reserve active surveillance for those men that have one, two or three biopsies, let's say, out of 12 that have prostate cancer and in each of those pieces of tissue a low volume within those pieces.  So it's the classic turtle on the block, if you will, cancer, that is, what we feel like is a slow?growing cancer.  Those are what we call low?risk cancers.  Those would be the candidates for active surveillance.  

Andrew Schorr:

Okay.  So you have a patient who has chosen active surveillance.  Tell us what tests do they have?  How often do they have them?  What exactly does it mean for them? 

Dr. Lin:

I think that it's pretty clear that the monitoring schedule for men that have active surveillance is not completely set and standard.  What it usually entails, though, is serial PSA measurements, somewhere on the order of every six months as well as examinations with a digital rectal examination.  And then an important aspect of active surveillance is serial prostate biopsies as often as once a year, but then other centers across the world are doing the biopsies every other year or every third year.  Every institution has its own specific protocol that's in place for active surveillance, but it usually entails, again, PSA measurements, examinations and then multiple biopsies to ascertain whether the cancer is still considered low risk or whether there is more concerning aspects of the cancer on the biopsy. 

Andrew Schorr:

Dr. Lin, for many years you have been one of the leaders in a clinical trial, the PASS Study.  What is the PASS Study, and is it still an opportunity for men today? 

Dr. Lin:

Yeah, so the PASS Study is a novel, very unique study.  The PASS Study stands for Prostate Active Surveillance Study, and this study was started approximately six to seven years ago.  It was funded by a unique foundation called the Canary Foundation that's based in the Bay Area in California.  And this is a foundation that funds the early detection, so the canary in a coal mine aspect, that was what it was for and multiple different types of cancers.  And this study is also supported by the NCI and the Early Detection Research Network or the EDRN. 

And the goal of the PASS Study, and it is now the largest study in the world, the prospective study, to understand men that have chosen active surveillance, and the goal is to find biomarkers.  So biomarkers are those markers that might be in the tissue, the urine or the blood of our patients that can give us an indication of the cancer beyond what we already listed, which was the PSA and the Gleason score. 

And so the goal of this study was to study, now we have over 1,200 men over time, and we gather their specimens. And we follow them not only to understand how they do on active surveillance but also to try to discover new ways of telling a man whether he should get treatment instead of active surveillance or conversely whether the cancer appears by these new novel biomarkers to be more indolent and that it would be safe for him to forego treatment and the side effects and to go on with active surveillance. 

We've been going on, again, as I said, for about eight years, coming up on eight years now, and we have built this machine, and now we're getting more funding from the government and other agencies. And I hope that in a few years you and I will talk again about some novel discoveries within active surveillance that we don't have at this point in time. 

Andrew Schorr:

So active surveillance may be one option, but I'm sure with your patients you discuss other options as well. 

Dr. Lin:

Definitely.  And I think I—I stress many, many times to my patients that they do have multiple options.  Even in this so?called low?risk prostate cancer, the slow turtle on the block prostate cancer, if one looks at the national guideline statements, such as the NCCN guidelines, which is generally accepted as one of the places to go to find out how to treatment different types of cancers, if you look at those guidelines and one looks at the low?risk prostate cancer, there are three options, and they're all equal.  Active surveillance, radiation and surgery are the primary three, and you can see that one is a no therapy option, and then there are two that are radical therapies with side effects, all equal. 

And so I put there to my patients that we individualize our treatments.  There are some patients that despite looking like a low?risk prostate cancer would probably not be the best patient for active surveillance based on other factors, perhaps such as they don't want to have serial biopsies.  They're very anxious about their prostate cancer.  Perhaps it's in multiple areas of the prostate that we feel like might not be the best candidate. 

Similarly, there are patients that come in and say, I want surgery. But when we look at them and we understand their history, perhaps multiple surgeries, perhaps very sick patient that would not withstand surgery, we might steer them in a different way.  So here at the SCCA, we certainly personalize our treatment based on the patient, but there are multiple options, as you said, for newly diagnosed prostate cancer. 

Andrew Schorr:

Dr. Daniel Lin from the Seattle Cancer Care Alliance, thanks for on update on active surveillance, and we'll look forward to you keeping us posted on how all this research pans out.  Hopefully, one day we'll be talking about a cure for prostate cancer.  Thanks for being with us. 

Dr. Lin:

Thanks so much. 

Andrew Schorr:

I'm Andrew Schorr.  Remember, knowledge can be the best medicine of all.  

Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.