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+++++++++++++++++++++++++++++++++++++++ + +++ + MEN'S HEALTH SPECIAL SECTIoN +++ +++++++++++++++++++++++++++++++++++++++ Active Surveillance for Low-risk Prostate cancer Patients by robert abouassaly, mD, mSc IN OUR UNDERSTANDING Of prostate cancer, we've come a long way. Years ago, every patient with prostate cancer underwent major curative treatment which usually involved a radical prostatectomy. This was frequently associated with high morbidity, including significant blood loss occasionally requiring blood transfusions during surgery and, post-operatively, urinary incontinence and erectile dysfunction — which could potentially be lifelong. So the short- and long-term side effects were significant. In 2012, the U.S. Preventive Services Task Force reported that the majority of men who were subjected to these harms would have remained asymptomatic during their lifetime and issued this statement, "Do not use prostate-specific antigen (PSA)-based screening for prostate cancer…The reduction in prostate cancer mortality 10–14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55–69 years." How small? According to the Task Force, with PSA screening, four to five out of every 1,000 men will die from prostate cancer after 10 years. In an unscreened population, about five of every 1,000 men will die from prostate cancer after 10 years. Clearly, the benefits do not outweigh the harms. Active surveillance as a viable option 28 | Cleveland/Akron/Canton MD News for patients with low-risk prostate cancer was backed by the National Institutes of Health (NIH) during a State-of-the-Science Consensus in December 2011. Instead of patients being aggressively treated, the NIH recommended that these patients be closely followed. The hope is to minimize treating patients whose disease does not show signs of progression and, at the same time, potentially cure those patients whose disease does progress and shows evidence of more malignance potential. The active surveillance approach is not new. Until recently, however, it was problematic. PSAs alone are not reliable, as indicated by recent publications. Serial biopsy can be misleading due to inadequate sampling in the anterior portion of the prostate or in the transitional zone. In the past few years, however, imaging — specifically, MRI — has shown promise when coupled with PSA's and biopsy to stratify prostate cancer patients' risk. For patients diagnosed with what appears to be low-volume, low-risk prostate cancer based on Gleason Score of usually six and a few cores that are positive for prostate cancer, those patients were usually followed with PSAs every three months for the first two years; then every six months after that. Now at about three to six months, MR imaging is incorporated. MRI of the prostate has increased in sophistication significantly in the past few years. And more and more ■ MDNEWS.COM ■ JULY-AUGUST 2013 clinicians have incorporated MRI into the follow-up of patients on active surveillance. Investigations on the use of quantitative data convergence to more accurately identify aggressive disease on MR imaging are currently underway. Genetic tests may also identify signs of aggressiveness in prostate cancer patients. One test, the Prolaris by Myriad Genetics, incorporates genetic markers for cell-cycle proliferation. Research has shown in a large population of patients who were not treated that Prolaris test results correlate well with the risk of dying of prostate cancer within 10 years. More genetic tests are on the horizon to help guide physicians and their patients through the decisionmaking process. An estimated 238,590 new cases of prostate cancer will occur in the United States in 2013 according to the NCI. The overarching question for the medical community is: "Are patients diagnosed with prostate cancer being overtreated?" The answer, according to the U.S. Preventative Services Task Force is: "They were." The urologic community has responded with new and improved selection processes for determining which patients are at higher risk of dying of prostate cancer and which patients are at lower risk and likely to die of other causes. For the latter patients, active surveillance has the potential to become a new standard of care. Dr. Robert Abouassaly is a urologist at University Hospitals Case Medical Center, Urology Institute Urologic Oncology Center, and an assistant professor at Case Western Reserve University School of Medicine. ■

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