Localized prostate cancer: principles of active surveillance, surgery, and follow-up

When diagnosed with localized prostate cancer, patients have three traditional options: active surveillance, surgery, or radiation therapy. Active surveillance involves closely monitoring the cancer without immediate treatment, radiation therapy uses radiation to kill the cancer while leaving the prostate in the body, and surgery (radical prostatectomy) involves removing the prostate gland. Other options under investigation include various forms of “focal” therapy that also leave the prostate gland more or less intact (cryoablation, high-frequency ultrasound, photodynamic therapy, electroporation, etc).

Patients on active surveillance undergo regular PSA tests, prostate exams, MRI scans, and repeat surveillance prostate biopsies, as indicated, to monitor the cancer’s behavior. The intensity of monitoring may vary depending on risk-level features of the cancer and the patient’s life expectancy. Genomic testing of the patient’s blood or saliva (germline testing) or the tumor cells in the biopsy specimens (somatic testing) may help determine if active surveillance is safe and how intensive it should be. Multiparametric magnetic resonance imaging (MRI) can complement risk assessment by detecting aggressive disease missed with the initial biopsy procedure. However, MRI is not an adequate replacement for periodic surveillance biopsies. More research is needed to determine optimal surveillance guidelines.

Regular follow-up with PSA tests and symptom assessments is crucial after treatment to monitor for recurrence and complications. PSA or rectal examination evidence of recurrence after treatment, positive surgical margins, and lymph node metastases may indicate the need for additional secondary treatments versus watchful waiting.

Support resources and services available throughout the prostate cancer journey, include social work, support groups, dietary services, and psychosexual therapists, to improve patients’ quality of life.

Journal of Urology.https://doi.org/10.1097/ JU.0000000000002758