Low-risk prostate cancer management – an overview

This review examined recent findings and recommendations for the management of low-risk localized prostate cancer. Authors concluded that watchful waiting and active surveillance are suitable options for most men with low-risk prostate cancer.

Due to advances in the early detection of prostate cancer, many prostate tumors currently being diagnosed are localized, small, early stage, and low-risk. Despite this, it is estimated that about 40% of prostate cancer patients are overtreated. This results in unnecessary side effects, such as urinary, sexual, and bowel dysfunction. An alternative to treatment is watchful waiting (waiting until significant symptoms occur). This is often recommended for men who are unlikely to benefit from treatment due to older age or other medical conditions. Another alternative is active surveillance, involving regular tests and active monitoring of the tumor. A better understanding of the proper management of low-risk localized prostate cancer has become increasingly important.

The aim of this review was to provide an overview of findings for low-risk prostate cancer.

Suitable candidates for active surveillance or watchful waiting should have very low or low risk prostate cancer. This typically involves a tumor stage of less than 2 and PSA (prostate specific antigen, a protein present in prostate cancer) levels less than 10 ng/ml. It also includes less than 2 or 3 tissue samples positive for cancer during a biopsy, and Gleason score (agressiveness of cancer cells) less than 6. 

In one trial, men with low-risk prostate cancer were randomized to either undergo prostate surgery or watchful waiting. While surgery was overall associated with better cancer-specific survival, no significant differences in survival were noted among men aged 65 years or older. Prostate cancer patients managed with watchful waiting have better urinary and erectile function in the initial 2 to 5 years after diagnosis compared to men treated with surgery. However, bowel function and overall quality of life did not differ at 5 years. Some men experience increased anxiety and depression during watchful waiting.

Young and healthy patients may require more intense surveillance to monitor the risk of disease progression. On average, about 25 to 33% of men undergoing active surveillance received their delayed treatment within 1.3 to 3.5 years after diagnosis. 5-year treatment-free survival (time without needing treatment) was around 60 to 80%. This reduced to about 50% at 10 years. One large study of 1,000 men undergoing active surveillance reported a mortality rate due to prostate cancer of only 1.5% (follow-up period was 20 years).

Most methods of assessing disease progression include PSA. Men with a PSA doubling time (the time until PSA levels increase 2-fold) of less than 3 years had a higher risk of cancer-specific mortality. Other factors include Gleason score, tumor stage, tumor volume, and the number of tissue samples during a biopsy testing positive for cancer. 

During active surveillance, regular rectal examinations are performed and PSA levels are frequently monitored. A repeat biopsy should be carried out within 3 to 6 months of diagnosis among patients considering active surveillance. Imaging techniques such as MRI (magnetic resonance imaging) can be used to identify prostate cancer and guide biopsies. Two separate studies reported that MRI-assisted biopsies identified more high-grade (aggressive) cancers than conventional biopsies.

Authors concluded that delaying treatment is a suitable strategy for the management of most low-risk prostate cancers.

Discuss with your doctor the different treatment strategies available to you.