Clinical studies examine the concept of „active surveillance“ also known as watchful waiting as an alternative therapy
Due to improved examination methods, prostate carcinoma is more often discovered at an early stage. At the same time, it is often questionable whether all of the diagnosed tumors need to be treated or removed with invasive therapies such as the radical surgery. Alternatively patients with a low-risk prostate carcinoma could be closely monitored. Whether the concept of „active monitoring“ is indeed beneficial, is currently being analyzed in an extensive international study.
For patients with a low-risk prostate carcinoma the „active surveillance“ constitutes yet another therapy, namely the so-called “non-treatment”. During the first two years, the tumor is being monitored every three months by determining the PSA (prostate specific antigen) level, and performing digital-rectal examination as well as image providing procedures. The prostate biopsy is monitored every 12 months. If the PSA level remains constant, the examination period is extended for another six months. However, if there are first signs of a progression of the decease, appropriate therapy is being decided upon. “The goal of active surveillance is to maintain a good life quality while simultaneously allowing for possible treatment, if needed, at a later point.” Explains Dr. Pedram Derakhshani, urologist at the West German Prostate Center Cologne.
More than 30 percent of the patients receive treatment after three to four years
Currently this treatment concept is being examined in an extensive international study1. The first results were introduced at this year’s Annual Congress of the European Association of Urology in Vienna (EAU). The study included a total of 1600 patients that evidenced low-risk prostate carcinoma (PSA<10; PSA/Prostate Volume<0,20; Gleason Score = 6; T1c or T2).
The results are worse than had previously been anticipated. Based on an elevated PSA level or worsened biopsy findings, every third patient had to undergo active treatment within three to four years. Additionally, aggressive tumors that had already exceeded the capsule limit were found repeatedly. Treatment in such cases is then often too late, because metastases could possibly have formed already.
Side effects of the treatment: Brachytherapy
“We are still not able to monitor patients with a low-risk tumor to make sure that we can intervene always on time in cases were the disease has progressed", emphasizes the Cologne urologist. "At present it is only possibility to administer a therapy that has fewer side effects. Radical treatment such as surgical removal of the prostate are not justified because of the frequent complications such as incontinence and erectile dysfunction".
O the other hand, it was found that a non-evasive yet effective treatment of prostate cancer is the brachytherapy (internal radiation). This smallest radiation sources (seeds) are placed directly into the prostate. "Through a precise distribution of the radiation dose, we can irradiate the tumor without damaging the surrounding tissues, such as urethral, bowel or sphincter", said Derakhshani. Thus, several studies show that erectile dysfunction and urinary incontinence occur much less frequently when compared with the prostate surgery (14% vs. 70%.and 0.3-3% vs. 50%).2
Living with the tumor: causes mental stress
In addition, the active monitoring of the tumor leads in many patients to mental stress and possibly it significantly decreases the quality of life. "Patients live with the knowledge that there is a tumor in their body that can change every day in size, extent, and aggressiveness," says Derakhshani. And in his experience, not all patients can deal with this kind of mental stress.
1Source: 26th Annual congress of the European Association of Urology (EAU) 2011
2Chen R.C.; Clark J.A., Talcott J.A.,: Individualizing Quality-of-Life Outcomes Reporting: How localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel and sexual function; Journal of Clinical Oncology, 2009, 27(24), 3961-3922