Active surveillance at local prostate cancer
Several new studies confirm that, with a localized prostate cancer, treatment may be initially postponed, but only under certain well-defined conditions.
With the active monitoring (engl. active surveillance) refers to the postponement of a curative (healing) therapy, which is possible, but not required, the patient is closely monitored and treated if the disease progresses. The aim is, possible complications of therapy for the time being, or - in case of non-progression - even to avoid the long term.
Such an approach can be chosen in order to avoid "treatment" that is an engaging therapy as an at local, limited to the prostate prostate cancer radical prostatectomy or radiation, where parties in whom the tumor had caused his lifetime no complaints and no would have died of it.However, it is not yet clear to which patients this is the case with sufficient certainty, which affected so active monitoring may be recommended. To this end, recent studies have now been published:
After a review (Weissbach) the number of radical prostatectomies is steadily increasing, especially in patients in whom, according to latest guidelines for active monitoring would be possible. It is already used in many guidelines as approved (EAU 2007), equal (Finland) or even sole (GB) treatment option for prostate cancer called low-risk (low-risk PCa). Such is up to 47% of the cases and is defined according to the D'Amico criteria: PSA value to 10ng/ml,Gleason score and clinical stage up to 6 T2a (tumor in more than half a prostate page, for TNM system see the growth and spread of prostate cancer ).
In addition, studies were evaluated with actively monitored patients: 8-33% of the tumor progressed during an average of 40 months, of which at half within 33 months. The authors recommend to risk prediction instead of the D'Amico criteria the so-called CAPRA score (CAPRA = Cancer of the prostate risk assessment) or the Kattan nomogram. In the first year should DRE ( DRE ) and PSA level (also slew rate = PSA-V, doubling time = PSA-DT; see alsoPSA test ) every 3 months will be controlled every 6 months thereafter. A Rebiopsie (repeat sampling; see also prostate biopsy ) after 6 or 12 months, later every three years could be a deterioration of the Gleason score detect in time.
A new retrospective study (Eggener) consisted of 262 men with prostate cancer who were true to the following conditions: Up to 75 years old, D'Amico criteria are met, up to 3 positive (infected) samples in the prostate biopsy, Rebiopsie before active surveillance and no treatment in the first 6 months. Of them were still treated within 29 months 43 (16%). The calculated probability after 2 and 5 years are still under active surveillance was 91% and 75% respectively. Of the 43 patients treated were 41 (95%) for an additional 22 months no evidence of progression of the disease. The authors therefore maintain active surveillance in selected patients over said time for sure, but require prior Rebiopsie.
In another study (Conti) the histological (histological) evidence of men were checked after radical prostatectomy, on the inclusion criteria of 5 studies were true for active surveillance, so it could participate. The Gleason score had postoperatively in 28% (23-35%) of the cases to be adjusted upward (upgrading, at least 7, 83% from 6 to 7) and remained at 10% down (downgrading) at 62% he same. Also, the stage turned after surgery often than higher out than before clinically evident (upstaging): In 7-19%, a breakthrough of the prostate capsule involvement of the seminal vesicles was (pT3a), at 2-9% (pT3b).
The values were lowest in the most stringent inclusion criteria, but these were also met by the fewest. These were related to expected tumor size (number of positive biopsies and percentage infestation of the sample) with a. It should therefore be taken into account when deciding on the active monitoring, according to the authors.
A similar conclusion was also another study (Helpap) in which were evaluated the biopsy findings and PSA levels of men with prostate cancer: It showed a PSA level below 10ng/ml, an infestation of only a sample and a total infestation to 20 % a relationship with a Gleason score to 7a (= 3 +4, low-grade tumor). This auditioned for a stage T2a and was especially in the age of 60-70 years the case. In a PSA value 10ng/ml, an infestation of at least two samples and a total infestation from 20% against a Gleason score from 7b (= 4 +3, high-grade tumor), which usually prevailed at 70-80 - year-olds occurred and suggested a stage of at least T2b. At very low PSA levels (under 2ng/ml) Gleason scores were evenly distributed.
Only 4% a PSA level up to 10ng/ml, an infestation of only a sample and a total infestation found to 1% (1 mm). Only then, according to the authors, probably could constitute an insignificant (not requiring treatment) prostate cancer, the definition was narrower than the modified Epstein criteria as above. And only then active monitoring was feasible.
Conclusion
Active surveillance for localized prostate cancer does have some disadvantages: The tumor could be malignant be (a higher Gleason score have) and have continued to spread, as clinically evident, the time for timely intervention might be missed, and the person would have with the fear live before proceeding. However, these risks can be reduced if the active monitoring is carried out according to strict criteria and regular, careful controls. How can you benefit be used avoiding a possibly unnecessary, engaging treatment with perhaps serious complications. The decision is always difficult and take only individual in the conversation between doctor and patient.
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