What is Active Surveillance?
More than 200,000 men will develop prostate cancer this year, making it the #1 cancer after skin cancer. Almost 30,000 men will die of prostate cancer, second only to lung cancer. There is much controversy surrounding the PSA test. One of our best markers for detecting prostate cancer has been the PSA test. However, critics point to the risks of overdiagnosis and overtreatment of indolent cancers that would otherwise not have impacted the patient. As such active surveillance (AS) has become an option in select patients.
What is active surveillance?
AS is a reserved for patients with low grade, low volume cancer. Specific criteria often vary but usually include age, PSA density (PSA/prostate volume), percentage of positive biopsy cores, the extent of prostate cancer in any core, and measures of PSA kinetics, such as PSA velocity. Patents undergo regular visits, PSA testing and repeat biopsies instead of upfront aggressive treatment. It is different than “watchful waiting” which is typically offered to older patients with significant comorbidities where life expectancy is not expected to be impacted by treatment.
Intervention will occur if there is evidence of tumor progression. This can include PSA change, changes in clinical staging or imaging, and findings on repeat biopsy that are indicative of a larger or higher-grade cancer, i.e. increased Gleason score or increased volume of tumor in the core biopsies.
Pathologists play an important role on the care team. Criteria need to be reproducible so that reporting is consistent and accurate, demonstrating the crucial role of pathologists in determining eligibility for AS. There needs to be dialogue between pathologists, urologists and other clinicians on the care team.
What to look for in the pathology report
Here are some of the criteria that should be in the pathology report:
Number of positive cores
Location of positive cores
Gleason grades and score
Other (reported only if present)
Other atypical acinar foci suspicious for carcinoma
Ask to see your pathology report. Understand the findings. Make sure the pathology lab is accredited, such as by the College of American Pathologists, and the pathologists are board certified. Ask whether there is a tumor board. A multidisciplinary team approach is the best for patient care. Experience matters.