Active surveillance for prostate cancer

The concept of Active Surveillance is increasingly emerging as a viable option for men who decide not to undergo a radical treatment immediate for the prostate cancer, such as surgery or radiotherapy.

Active surveillance is based on the concept that it is certain types of prostate cancer, defined as “low risk”, have a low probability of evolving into an aggressive disease and thus reducing life expectancy.

Over 30% of men with prostate cancer have such slow-growing disease that the side effects of radical treatment far outweigh the benefits.

Of the 10 most common cancers, prostate cancer is the only one in which so many patients have a slow-growing disease that does not warrant immediate aggressive treatment.

But beware: active surveillance is not a “non-treatment”, but rather a strategy to treat you only if and when your prostate cancer actually requires treatment.

It may seem counterintuitive to say that a patient has cancer and the best thing is to sit and wait. But studies show that men with low-risk prostate cancer who have been in active surveillance for 10-15 years after diagnosis have remarkably low rates of disease spread or death from prostate cancer.

In fact, a study by the Johns Hopkins on men in active surveillance found that less than 1% of men developed metastatic disease in 15 years of monitoring. This is extremely important because the treatments used for localised prostate cancer - surgery and radiotherapy - have side effects that can alter a person's quality of life.

The key to successful active surveillance is obviously regular monitoring in order to intervene at an early stage when there are signs of progression.

Who can consider active surveillance?

Patients who may consider active surveillance following a diagnosis of prostate cancer must obviously have localised disease at low risk of progression.

In general, the characteristics of the tumour to be considered a candidate for this type of approach must be :

• a histological diagnosis with a Gleason score maximum of 6 (indicated as 3+3) or, only for an age over 70, of 7 (indicated as 3+4);
• Of all the biopsy samples, only 1 or 2 must be positive for prostate cancer;
• have a value of PSA in the blood equal to or less than 10 ng/ml;
• have a small tumour that does not exceed the capsule lining the prostate, defined as stage T1c or T2a;

Surveillance or therapy: the choice is always the patient's

Patients with newly diagnosed localised prostate cancer at low risk of progression are provided with information on various types of treatment available to date.

The duly informed patient is invited to discuss this with his or her doctor and persons he or she trusts, and will then be able to choose spontaneously whether to enter the active surveillance programme or to resort to surgical or radiotherapeutic treatment, obviously if appropriate to the specific situation.

Active surveillance in Italy

In Italy, there are some active surveillance protocols in which it is possible to participate.

In various parts of our country, the study is active PRIAS promoted by the urology society SIURO, while in Piedmont and Valle d'Aosta recruitment is active for the study START.

They are “observational” studies because they do not involve testing drugs or new technologies. They consist exclusively of collecting information on the patient's state of health over time, whichever treatment he or she decides to undergo among the various possible options.

In particular, information is collected on the patient's quality of life, by means of simple questionnaires to be filled in at the start of treatment and then periodically at the usual check-ups, where, in addition to checking PSA values and the objective examination, imaging examinations may be carried out, such as a multiparametric MRI.