The James Buchanan Brady Urological Institute
 
 
 
  PROSTATE CANCER          Appointments: 410-550-6100

Our Surgeons

Mohamad E. Allaf, M.D.

Trinity J. Bivalacqua, M.D, Ph.D 

Arthur L. Burnett, II, M. D.
 

H. Ballentine Carter, M.D.


Misop Han, M.D.

Jacek L. Mostwin, M.D., D.Phil,(Oxon.)


Alan Partin, M.D., Ph.D

Christian Pavlovich, M.D.

Edward M. Schaeffer, M.D., Ph.D. 

Patrick C. Walsh, M.D.


ACTIVE SURVEILLANCE FOR PROSTATE CANCER: WHAT A MAN NEEDS TO KNOW BEFORE DECIDING ON TREATMENT    

RELATED RESOURCES:
Active Surveillance
Prostate Cancer Active Surveillance

The Brady Urological Institute has achieved world renown for discoveries that led to improvements in the surgical treatment of prostate cancer. However, not every man will benefit from treatment since some cancers will never progress to a harmful state. Researchers at the Brady Urological Institute have a commitment to learn how to identify those men who can safely forego treatment -instead undergoing careful follow up for any evidence of progression of their disease (active surveillance). An active surveillance program at the Brady Urological Institute under the direction of Dr. Ballentine Carter and Dr. Jonathan Epstein has followed more than 900 men over more than 15 years who are thought to have tumors that can be safely managed without immediate treatment.

The Johns Hopkins Active Surveillance Program is unique:

  • Largest and longest ongoing surveillance study using strict criteria for recruitment
  • Strict recruitment criteria developed at Johns Hopkins
  • Close follow-up of men, with annual prostate biopsies performed using techniques that are based on original studies from Johns Hopkins
  • Collection of blood and urine samples for future studies
  • Multidisciplinary team of dedicated urologists, pathologists, radiologists, statisticians, basic scientists, and clinical coordinators working together to improve patient care through discovery
  • Latest research findings translated into patient care before they become available to the medical community

People Involved in the Active Surveillance Program

Clinical Coordinators

Patricia K. Landis, BA
Senior Research Coordinator

Sacha Wolf, BS 
Research Coordinator

Multidisciplinary Team
Urology

H Ballentine Carter, MD
Director of Adult Urology, Brady Urological Institute
Program Principal Investigator

Urologist that Monitor Participants

Mohamad E Allaf
Trinity J Bivalacqua
Arthur L Burnett
H Ballentine Carter
Misop Han
Alan W Partin
Christian Pavlovich
Ronald Rodriguez
Edward M Schaeffer

Pathology

Jonathan I Epstein, MD
Director of Surgical Pathology, Johns Hopkins Hospital
Program Co-Principal Investigator

Lori Sokoll, PhD
Clinical Chemistry
Program Investigator

Epidemiology

Bruce J Trock, PhD
Director, Division of Epidemiology
Program Investigator

Radiology

Katarzyna J. Macura, MD, PhD
Program Investigator
Basic Sciences

William B Isaacs, PhD
Program Investigator

Jun Luo, PhD
Program Investigator

Robert Veltri, PhD
Program Investigator

Which patients are the best candidates for no immediate treatment or active surveillance?
Prostate cancer is the most prevalent male cancer, but the majority of men with the disease do not die of prostate cancer. Studies suggest that 30-50 percent of men over the age of 60 years diagnosed with prostate cancer today by PSA screening undergo a treatment that will not extend their life or improve its quality. This does not mean that prostate cancer does not kill men, but rather that some men who are older and/or in poor health with a slowly progressive form of the disease, may not need immediate treatment. The key is to identify the men who for now can safely forego treatment.

Eligible men should meet the following criteria for Very Low or Low Risk Disease:

Very Low Risk Prostate Cancer

  • Life expectancy less than 20 years
  • Cancer not felt on digital rectal examination (stage T1c)
  • PSA density (PSA divided by prostate volume) is less than 0.15
  • Gleason score is 6 or less with no Gleason pattern 4 or 5
  • No more than 2 cores with cancer, or cancer involving no more than 50% of any core on at least a 12 core biopsy

Low Risk Prostate Cancer

  • Life expectancy less than 10-15 years
  • Cancer not felt on digital rectal examination and/or small nodule (stage T1c or T2a)
  • PSA below 10ng/ml
  • Gleason score is 6 or less with no Gleason pattern 4 or 5 on at least a 12 core biopsy

Those men who are interested in active surveillance should contact Dr.Ballentine Carter at 410-955-0351.


What does active surveillance mean? 
In the past, the term watchful waiting meant no treatment until the development of metastatic disease, at which time androgen ablation (hormonal) therapy was initiated. Today, men who have very low to low risk prostate cancer, and who choose no immediate treatment as an alternative to immediate treatment, are closely monitored with intervention -if necessary- at a time when cure is still possible. We now refer to this as active surveillance (also formally called Expectant Management) with selective delayed curative intervention. This means that men undergo periodic evaluations including PSA tests, digital rectal examinations, and prostate biopsies. If there is evidence that the cancer is progressing, treatment is recommended with the intention of curing the disease.

Is it possible to accurately identify those men for whom surveillance is safe? 
Dr. Jonathan Epstein, an expert in prostate pathology at Johns Hopkins Hospital, has shown in two separate studies (one retrospective and one prospective) that cancers less than 0.5 cc (smaller than an eraser tip) can be identified correctly about 75-80 percent of the time using PSA and information from the prostate biopsy. Dr. Epstein's criteria provide a method for helping men choose between immediate treatment and active surveillance.

The Original Epstein Criteria for Very Low Risk Disease:

  • Cancer not felt on digital rectal examination (stage T1c)
  • PSA density (PSA divided by prostate volume) is less than 0.15
  • Gleason score is 6 or less with no Gleason pattern 4 or 5
  • No more than 2 cores with cancer, or cancer involving no more than 50% of any core on a prostate biopsy

If a man decides on active surveillance, what recommendations are made for follow-up of the cancer?

  • 12-14 core prostate biopsy annually until age 75 years
  • PSA and free PSA every 6 months
  • Digital rectal examination at least yearly

Studies from our active surveillance program have shown that PSA level changes are not sufficient to alert us as to whether or not the cancer is changing. This necessitates surveillance biopsies for careful monitoring. During a surveillance biopsy, our studies show that it is necessary to sample the transition zone of the prostate (anterior prostate region), which is why we now perform a 14 core biopsy in most men undergoing surveillance. For those men that have 2 consecutive annual biopsies that show no cancer, we recommend that the interval between biopsies be lengthened to 18 months. Prostate biopsies may be discontinued at age 75 years, since prostate cancer is unlikely to cause harm beyond this age if a man has not yet had a change in the cancer with careful monitoring. 

Are there any other tests that are useful for predicting which prostate cancers need to be treated? 
We are actively investigating other biomarkers like proPSA (precursor form of PSA), and genetic markers that may help identify those men who do and do not need treatment. The value of an MRI in determining the best candidates for surveillance is being studied to determine if this test can help assess cancer extent prior to enrollment. 

How does a man who qualifies for surveillance make a choice between active surveillance and treatment? 
At the Brady Urological Institute we do not encourage healthy men in their 50’s to strongly consider active surveillance because of their longer life expectancy and time horizon for cancer progression. For older men, especially over age 65 years who meet criteria, active surveillance is one of the options that should be seriously considered. 
In a recent study with colleagues in the Bloomberg School of Public Health, we evaluated the factors that influenced a decision regarding active surveillance versus surgery using a computer simulation (Markov model). The men best suited for surveillance would appear to be those that:

  • have the ability to live with cancer without worry reducing their quality of life
  • are most concerned about the potential side effects of treatments
  • value near term quality of life to a greater extent than any long term consequences that could occur

Each man should carefully weigh the potential loss of quality of life with treatment (radiation or surgery), against the possibility that the window of opportunity for cure will disappear without treatment. 

What does a man have to lose with active surveillance of a PSA-detected cancer? 
The major concern is that while surveillance is taking place, the tumor will progress beyond the prostate to the point where cure is no longer possible. Our experience to date with active surveillance allows a number of conclusions regarding this risk.

  • About 30 percent of the men who have entered surveillance have undergone treatment within 5 years
  • High grade cancers that are Gleason score 7 or more are found on surveillance biopsies at a rate of about 4% per year
  • Most men who undergo treatment do not have high grade cancers
  • Recognizing the probability of death from prostate cancer among men who are treated for high grade cancers, we estimate that a man at age 65 years who enters surveillance with very low risk prostate cancer has
    • a 20 year risk of death from prostate cancer of approximately 5%
    • a 20 year risk of dying of another cause of approximately 60%

 

If a man chooses active surveillance, what dietary changes should he make? 
Most men ask what they should be doing in terms of lifestyle changes to help prevent progression of their disease. This is an area of intense interest now but it's one that is clouded by the fact that dietary supplements are a billion dollar industry in the U.S. This often makes it hard for consumers to distinguish between science and marketing. 
The Prostate Cancer Foundation (PCF.org) has a free guide that can be ordered from their website titled Nutrition, Exercise, and Prostate Cancer. I would advise all men with prostate cancer to read this. Also, the American Cancer Society has up to date information on lifestyle choices and cancer prevention. 
The bottom line is that a diet that is low in animal and dairy fat, high in a wide variety of fruits and vegetables and healthy grains and nuts, is thought be a diet that can slow the progression of cancer. Maintaining a healthy weight with daily exercise is also considered important.

Healthy Living Tips 
Recent studies have shown that a man’s lifestyle—especially nutrition and exercise—has a significant influence in prostate cancer prevention and treatment.

Follow these tips to help you live a healthier life (PCF.org):

  • Lose body fat by eating fewer calories per day than you burn
  • Maintain muscle mass by increasing protein intake and exercise
  • Cut carbohydrate intake to cut down on excess fat and weight, which can slow tumor growth
  • Exercise every day, combining cardiofitness and weight lifting
  • Eat nine servings a day of colorful fruits and vegetables
  • Reduce stress by focusing on living a balanced life and taking care of yourself
  • Plan ahead to eat healthfully and minimize stress
  • Track your behaviors and help chart your progress
  • Establish a support system by maintaining healthy relationships with people who understand what you are going through

 

 



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