Men, Prostate Cancer and the PSA Test: How Active Surveillance Helps Save Lives
Men trying to decide whether to have prostate-specific antigen testing (or, PSA testing) to check for prostate cancer have reason to be confused.
First, in 2012, the U.S. Preventive Services Task Force ruled against routine PSA tests, because they were leading to over-treatment of low-grade cancers that were never going to cause health problems.
That led to a drop in PSA testing, and that led to more men who weren’t tested coming to the doctor with more advanced cancers that are more difficult to treat.
So in 2017, the task force reversed course. The guidelines now say older men should talk with their doctors about PSA testing.
Two University of Wisconsin Carbone Cancer Center prostate cancer experts recently shared their thinking on how “active surveillance” walks the line between over-treating a slow growing cancer, and catching the malignant cancers that need immediate attention.
"Active Surveillance" for Prostate Cancer
What’s the first step for men concerned about their prostate health?
Jarrard: Men between the ages of 55 and 70 should have a talk with their primary-care physician. If they decide to get a PSA test, we look at the PSA number. Our level of concern varies by age, and it’s a complex issue. For example, at age 60 a marked rise in PSA, generally a PSA over 4, might suggest you should see a urologist for a biopsy.
Cooley: Of course, men with a family history of prostate cancer should have that baseline PSA test at age 50, or earlier.
What does a biopsy tell us?
Cooley: It tells us first if there is cancer. Pathologists look at the cells under a microscope and give it a Gleason score, which correlates with potential aggressiveness.
What is a Gleason score?
Cooley: It’s a predictive score developed by a pathologist, Dr. Gleason in the 1960s, which has held up over time. Historically the scale goes from two on the low end (1+1) , to 10 (5+5) on the high end. Anything below a 6 is rarely reported anymore, with some arguing whether all Gleason 6 should be considered cancer, yet even a very small percentage of these do metastasize. A newer grading system, the Grade Grouping (GG) approach, assigns aggressiveness based on 1-5 with the older Gleason 6 corresponding to a GG1.
Which patients do you recommend for active surveillance?
Jarrard: Gleason 6 patients are those usually considered for active surveillance. We also factor in the PSA level, the clinical exam, MRI findings, and the percentage of positive biopsies.
The men who are in the safest group are those with Gleason score 6, small nodules or non-palpable tumors, PSA less than 10, with a small percentage of positive biopsies. That’s the largest category of men we would consider for active surveillance.
The data show that over time, about 30 to 50 percent of these men will wind up receiving treatment because of rising PSA levels or changes in the Gleason score after a repeat biopsy. These studies are showing that it’s safe to watch these folks and treat them with progression, such that we aren’t losing the survival benefit of earlier treatment. The primary benefit is for those who never end up needing treatment.
We have published a number of studies here helping to figure out approaches to predict risk of failure on active surveillance early in the course those men. One recent paper looks at an algorithm based on clinical and pathological factors to determine risk.
What will active surveillance mean?
Jarrard: It means it isn’t necessary to treat these cancers, yet. But we do a PSA check every six months, and MRI images to help monitor the disease. Sometimes we do further biopsies and molecular testing on the tissue to look for changes that predict more aggressive cancer.
How do you decide when to do another biopsy?
Cooley: I agree with Dr. Jarrard. Historically biopsies have been recommended annually, which for some men, changed their mind about continued active surveillance. The last few years however in particular, with the use of MRI and its capacity to identify higher Gleason score cancers, PSA, and now genetic testing, which is still under study, are starting to modify those guidelines to reduce the number of biopsies needed.
How long do men stay in active surveillance?
Jarrard: At two years, about 20 percent of men progress to treatment with surgery, radiation or both. The number of men who “graduate” to the treatment group goes up as the years go on. We currently have hundreds of UW Carbone patients on active surveillance.
Date Published: 05/08/2018