"Active surveillance" is becoming increasingly common in the diagnosis and treatment of men with prostate cancer.
- 1 in 7 men are diagnosed with prostate cancer.
- Not every man with prostate cancer needs treatment.
- Men with slow-growing prostate cancer are the best candidates for active surveillance.
- In the future, programs like the ones at Yale Medicine may allow men to benefit from regular prostate imaging, a diagnostic approach similar to mammograms for women.
Richard Watson ran a successful company producing electric radiant heating systems and authored a handbook for his field, traveling as far as China to discuss international standards. He raised five children and had three grandchildren. He enjoyed playing tennis with his wife. His life was full, and he felt much younger than his age, 75.
Watson’s only outstanding health issue over the years was a gradual but steady rise in his body’s level of prostate-specific antigen (PSA), a protein produced exclusively by prostate cells. It was not something he had been overly concerned about, even though it can be an indicator of prostate cancer. Multiple biopsies had been negative; he had had no enlargement or swelling, no problems with urination and no pain.
In 2014, though, Watson’s PSA number climbed past 10—well above the low-risk 3 or 4 he had started with—and his urologist referred him to Yale Medicine. “Everybody has something in life they go through, and I’ve been lucky,” he says. “But my time came, so the key was to get the best person to help and the best technology.”
The question was: Where was the cancer?
The prostate is “the only solid organ in the body in which we can’t accurately view the cancer,” says Peter Schulam, MD, PhD, chair of the Urology Department at Yale Medicine. Previous tissue samples of Watson’s prostate yielded no proof of cancer. The reason, his urologist later concluded, was that the tumor was in a part of the prostate that is difficult to reach with traditional biopsy methods.
Yale Medicine’s “active surveillance” approach to monitoring the emergence and growth of prostate cancers means frequent checkups and high-tech monitoring tools. Using a device called Artemis, a 3-D imaging tool for targeting the biopsy, doctors found a one-centimeter lesion in the front portion of Watson’s prostate. (This area is further from the rectum, making it more challenging to sample through regular biopsy techniques.)
The imaging showed that he had an aggressive cancer. His Gleason score, used in prognosis, was 9 out of 10.
“They moved with dispatch,” Watson says. He had a radical prostatectomy, surgery to remove his prostate and surrounding tissue, in December 2015. He credits the Artemis with saving his life.
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Active surveillance is increasingly common in the diagnosis and treatment of men with prostate cancer. The goal is to diagnose aggressive cancers (the minority of cases) in time to treat them, while allowing men whose cancers are not life-threatening to avoid surgery.
Each year there are 100,000 to 120,000 radical prostatectomy surgeries to remove a man’s prostate gland, and Dr. Schulam believes some of them are unnecessary. “We over-treat prostate cancer in the United States,” he says.
Soon after joining Yale Medicine from UCLA in 2012, Dr. Schulam assembled a team of doctors, engineers and radiologists and put them to work on an approach to monitoring that included the multitasking Artemis device. This technology provides highly accurate information about the precise location of cancerous lesions in the prostate gland.
“The machine takes the MRI image and an ultrasound image and puts them together in a 3-D model,” says Preston Sprenkle, MD, a Yale Medicine urologist who oversees use of the MRI-ultrasound fusion prostate biopsy technology. The real-time ultrasound feature then “helps us guide where our needles go,” so biopsies are not as blind as they have been in the past.
When the team members examine a gland a second time, they have a superimposed image so “we can biopsy the exact same place as before,” Dr. Schulam says.
Dr. Sprenkle is gathering data to show the Artemis imaging device is helping patients make more informed decisions. “We’re getting better with more experience,” he says. “I would say we’re confirming that Artemis is superior to a standard biopsy in terms of cancer detection as well as the detection of aggressive cancer, which is really the only kind that needs to be treated.”
Opting for monitoring
Brad Davis, a veterinarian and a married man who had raised three children with his wife, was one of the early patients at Yale Medicine to be monitored with this form of active surveillance. A life insurance exam had turned up a high PSA, and a biopsy confirmed cancer. At 54, he had the same disease his father had been diagnosed with in his 60s. As a younger man, Davis faced an especially difficult choice.
Davis scoured the Internet for professional papers, gathered second opinions and made sure several doctors agreed on his Gleason 6 score, indicating the least aggressive kind of prostate cancer. One doctor told him he needed to move right away on a prostatectomy, which had a high risk of dramatically changing his sex life and might leave him with incontinence problems that could impact his career.
Instead, Davis has kept a close eye on his prostate health. He monitors his PSA level and gets a digital rectal exam every six months. He also visits Yale Medicine once every two years for an Artemis biopsy. “I’m 58 now, and the tumor hasn’t changed in three years,” he says. The one change he has noticed in three years of surveillance is that better topical anesthetics to block pain are making his biopsies more tolerable.
Looking to the future
Meanwhile, researchers encouraged by the program’s success are pondering new questions. For instance, would men in low-risk categories benefit from regular prostate imaging in the way some women benefit from regular mammograms? For some, the answer may be yes.
“This technology could start a new paradigm in treatment. For the right patient, this could potentially be the first-line treatment,” Dr. Sprenkle says.
The primary candidates so far are men with a Gleason score of 6 or lower and cancer in only a few biopsy samples; these men are considered to be at a low risk for developing symptoms. A recently launched clinical trial at Yale is studying whether men should also be considered if they have a family history of prostate cancer and the BRCA2 gene, which has been discovered to be responsible for a significant number of early-onset prostate cancers.
The doctors consider active surveillance to be a highly individualized choice. Davis is happy with his decision to forgo surgery and closely monitor his prostate health. “As long as you can go to bed at night understanding you have these potential cells that could be harmful, it’s fine,” he says.
He is symptom-free, and his PSA level is just 3.
As for 75-year-old Richard Watson, he has recovered from surgery. He says he is determined to see his grandkids grow up and “is planning for the next 25 years.”
Watson does not think about how things might have gone if he had not found the cancer. “There is nothing other than the Artemis procedure that would have gotten me to this stage. I was definitely in touch with the right people at the right time,” he says. “There were a lot of side effects from the surgery, but the mission was to get cancer-free. Mission accomplished.”