Howard Wolinsky is a medical journalist in Flossmoor, Ill., who knows better than to go forward with potentially life-changing surgery without first seeking a second opinion.
Nine years ago, at age 63, when a PSA blood test followed by a biopsy revealed cancer in his prostate gland, the diagnosing urologist said he could operate to remove the offending organ the following week.
Not so fast, Mr. Wolinsky thought, knowing this was not a minor operation that often left men temporarily or permanently impotent, incontinent or both. So, before going under the knife, he consulted Dr. Scott Eggener, a University of Chicago urologist, who reviewed the test results and proposed an alternative strategy called active surveillance.
Not to be confused with “watchful waiting,” active surveillance is not a do-nothing approach. Rather, patients are routinely monitored and referred for surgery or radiation therapy only if their cancer begins to grow or show molecular signs of aggression.
Current estimates are that about half of men found to have prostate cancer could avoid radical treatment and its potential side effects if they were willing to live with having a cancer, albeit a seemingly benign one, in their bodies. These are men whose cancer is deemed, based on its biological characteristics, to be low-risk of progressing to a potentially life-threatening state.
Only if periodic exams reveal that a man’s cancer is shown to be progressing to a more aggressive state would more radical treatment be considered. Within a decade, this generally affects about 5 percent of men who choose active surveillance, Dr. Eggener told me.
Other reasons for abandoning active surveillance and undergoing radical treatment include the patients’ growing anxiety about living with cancer and pressure from family members, and sometimes even from their doctors, to “get it out,” clinicians report.
Watchful waiting, which involves little or no monitoring, is still sometimes suggested but mainly reserved for men with a limited life expectancy for other reasons or those whose health status makes surgery inadvisable.
Based on his PSA of less than 4 and a Gleason score of 6, Mr. Wolinsky said, “Dr. Eggener told me ‘You’re the perfect candidate — the poster child for active surveillance.’” The Gleason score is a measure of the cancer’s aggressiveness, and a composite score of less than 7 is generally deemed low-risk disease.
So starting in 2010 Mr. Wolinsky had a PSA test and digital rectal exam every six months and an annual biopsy of the prostate, which was eventually lengthened to every three years. It’s now been four years since the last biopsy and chances are, unless a worrisome rise in the PSA occurs and other tests indicate an aggressive cancer, he may never need another.
Given the now rapidly changing methods of monitoring and diagnosing the lethality of prostate cancer, it behooves every man told he has cancer in this gland to explore the most currently available management options before deciding on treatment. There are now even support groups to help reassure men with a low-risk cancer who choose active surveillance.
“The field is on fire,” said Dr. Laurence Klotz, a leading expert on urological cancer and pioneer of active surveillance. “Within a few years, we’ll have urine and blood tests that are so reliable we’ll know which men don’t even need a biopsy. Instead of a biopsy, there are now at least five biomarkers and more being developed that can be used as an initial test.”
Even the process of biopsy has changed. For decades, when a possible cancer was suspected based on the PSA test or digital rectal exam, doctors blindly took 12 core samples from the prostate to search for a malignancy. Now an M.R.I. can be done first and a biopsy performed only if and when a potentially serious lesion is revealed. High-resolution ultrasound may even become a simpler and less expensive alternative to an M.R.I., Dr. Klotz said.
To avoid the need for a biopsy altogether, Dr. Klotz is leading a large Canadian clinical trial, called Precise, to determine if an M.R.I. is sufficiently accurate in detecting dangerous cancers and distinguishing them from harmless ones. He estimates, based on early data, that as many as 250,000 men a year in Canada and the United States could avoid unnecessary biopsies without compromising the ability to identify clinically significant cancers.
This approach results in the diagnosis of many fewer indolent cancers that would likely never threaten a man’s life, said Dr. Klotz, a professor of surgery at the University of Toronto and a mentor in the field of prostate cancer diagnosis. “With an M.R.I. we find fewer of these low-grade cancers, and fewer men will be overtreated,” he said.
If Dr. Eggener had his way, he would not even call it cancer for men who are given a Gleason score of 6 or lower, because “it fails to meet the clinical definition of cancer: the ability to cause symptoms, metastasize or lead to death,” he wrote in an email. “Removing the cancer label has been done in other cancers, most notably a subtype of thyroid and bladder cancers. I predict this will eventually happen for Gleason 6 prostate cancer, and in my opinion will be reason for celebration.”
As he has reported, “A high proportion of screen-detected cancers are Gleason 6, and their metastatic potential is negligible.” On biopsy, a cancer may contain cells with different Gleason grades, most commonly a mix of 3 and 4, and the total score adds together the most common ones found in order of their frequency. A pattern 3 has no ability to metastasize, but a 4 is aggressive, Dr. Klotz explained. Thus, a Gleason score of 3 plus 4 is considered less aggressive than 4 plus 3.
There are now genetic tests under study that could help identify the occasional prostate cancers with a low Gleason score that “are bad actors,” Dr. Klotz said. And Dr. Brian Helfand of NorthShore University HealthSystem in Evanston, Ill., and colleagues are studying genetic tests based on more than 100 variants of DNA that may enable men with a high PSA to skip biopsy altogether. At a meeting of the American Urological Association, European researchers described six proteins in the blood that can serve as biomarkers to identify men with an elevated PSA who can safely avoid a biopsy. Of 474 men in their study, 60 percent of the negative biopsies could have been avoided, they reported.