Nov. 7, 2023 -- When Allan Greenberg was diagnosed with prostate cancer in 2012, he elected to take a then-uncommon approach to treating the disease.
He did practically nothing.
Now, at the age of 83, with little to no change in Greenberg’s prostate cancer, the retired college professor is considering forgoing both active surveillance and treatment altogether in the winter of his life, but he hasn’t made his decision yet.
“At my age, treatment is the last thing I would consider,” Greenberg said from his home in Vermont. “Even if it has seemed that things were getting worse, I'm not sure I would undergo any treatment at this point.”
So if treatment is off the table, why even bother with surveillance?
That’s the question thousands of aging men must consider as the likelihood appears low they will die from a low-grade prostate cancer diagnosis made a decade or more earlier.
Active surveillance for prostate cancer replaces radiation treatment or a prostatectomy with regular monitoring. Surveillance can include prostate-specific antigen (PSA) blood tests, MRIs, and biopsies.
Active surveillance is intended for only grade 1, or low-risk, prostate cancers and some low-risk grade 2s.
Prostate cancer ranges from grade group 1 (lowest grade) to grade group 5. A Gleason score is the traditional system for classifying how severe the cancer is. Cells are graded on a scale of 1 to 5 based on various factors. A pathologist will assign one Gleason grade to the most predominant pattern in a biopsy and a second Gleason grade to the second most predominant pattern. A Gleason score of 3+3, for example, is considered low grade.
“There's a wealth of literature showing that grade group 1 prostate cancer, in particular, is very, very different from other types of cancer,” said Kevin Ginsburg, MD, an assistant professor of urology at Wayne State University School of Medicine in Detroit. “As a consequence of that, the harms of treatment often very frequently outweigh the benefits."
Ginsburg, who is also the prostate program co-director at the Michigan Urological Surgery Improvement Collaborative, says the drawbacks of active surveillance -- the cancer spreading and killing the patient -- are low. A study from Johns Hopkins looking at a group of more than 1,800 men found that “the risk of cancer death or metastasis was less than 1% over long-term follow-up.”
“I firmly believe that with good high-quality active surveillance, the chances of missing the ability to treat and cure someone if and when that point arises is very, very, very low,” Ginsberg said.
The benefits of active surveillance include avoiding debilitating treatments that can leave a patient incontinent or impotent. For many men who choose active surveillance, it's a quality-of-life issue. Prostate cancer is slow-moving, which lends itself to monitoring.
Cancer in Lowercase
Laurence Klotz, MD, a urologist at the University of Toronto, named and helped establish active surveillance more than 30 years ago. Back then, 95% of men with low-grade prostate cancer were being treated.
Now, active surveillance is the preferred option for low-risk cancer. The number of men with prostate cancer who opted for active surveillance doubled nationally between 2014 and 2021, with about 60% of men eligible for active surveillance choosing it. That’s up from 27% in 2014 and 10% in 2010.
A recent study out of Italy found that 83% of men chose active surveillance over immediate treatment. Last year, the American Urological Association and the American Society for Radiation Oncology strengthened their recommendation for active surveillance.
Klotz sees advanced technology as the “malady of modern medicine.” More sophisticated diagnostic tools can lead to overdiagnosis -- and thus overtreatment -- in any specialty, including prostate cancer.
“We'd be better off in the diagnostic strategy where this wasn't identified at all,” Klotz said. “The majority of prostate cancers do not pose a threat to the patient.”
Michael Leapman, MD, an associate professor of urology at the Yale School of Medicine in New Haven, CT, notes that PSA blood tests are effective at identifying early-stage prostate cancer but not so great in distinguishing between aggressive and less worrisome tumors.
“The movement for active surveillance is really born out of the recognition that there are a large number of prostate cancers that are classified as prostate cancer, but they're indolent and are unlikely to cause a problem in a man's life,” Leapman said.
Some experts are even pushing to stop calling early, low-grade prostate tumors “cancers.”
Daniel Lewis, MD, an internal medicine doctor with the Facey Medical Group in Los Angeles, said a patient's decision to go on active surveillance is influenced by their tolerance for risk. When one of his patients receives a diagnosis of prostate cancer and elects to have active surveillance, he asks if they want a second opinion. Lewis, also chairperson of the Black Physicians Council at Facey, often sees looks of relief on the faces of patients who don’t need treatment.
Dying With -- Not From -- Prostate Cancer
Participating in and stopping active surveillance are personalized decisions for patients. Factors to consider include quality of life, age, overall health, and life expectancy.
Some men reduce their active surveillance later in life, opting for only the occasional PSA test. Others stop surveillance altogether, having lived a long life and choosing not to invest time in surveillance of something that, by that point, is unlikely to be the cause of their death. While some men may continue surveillance for peace of mind, others discontinue because, well, why not?
Ira Kaget was diagnosed with low-level prostate cancer in March 2009 at the age of 66. After the initial shock, Kaget, now 80, researched the topic and spoke with experts. With his Gleason score a mere 3+3 and the horror stories he heard of men who regretted treatment, he opted for active surveillance. He gets an MRI-informed targeted biopsy every 2 years and frequent PSA tests.
Now, almost 15 years after his initial diagnosis and little change to his condition, Kaget has no plans to change course.
“I plan to continue with this, continue monitoring, and I'm very intent on managing my case,” Kaget said. “The goal is to die with it instead of because of it.”