Low-risk prostate cancer: Active surveillance or treatment?

Men with low-risk prostate cancer have four treatment options:

• Active surveillance involves monitoring the prostate cancer, and only treating it if there are signs that it is progressing.
• In external radiotherapy, the cancer is exposed to radiation from outside the body, through the skin. The aim is to destroy the cancer cells.
• In internal radiotherapy (brachytherapy), the cancer is exposed to radiation from slightly radioactive “seeds” (about the size of a grain of rice) that are implanted inside the body. These are inserted directly into the prostate in a minor procedure. Here too, the goal is to destroy the cancer cells.
• The aim of surgery (radical prostatectomy) is to remove the tumor, together with the whole prostate, seminal vesicles and outer capsule. This can be done using open surgery with a slightly larger incision, for example between the testicles and anus. It is also possible to perform the surgery through several small incisions in the lower abdomen – with or without the use of a robot.

Radiotherapy and the surgical removal of the prostate are also referred to as “curative” treatments because the aim is to remove all of the tumor cells. But a few cancer cells may stay in the body, or new cancer cells might develop. For this reason, men who have had radiotherapy or surgery are still advised to have regular PSA tests.

The medical societies in Germany recommend first using active surveillance for low-risk prostate cancer. This involves checking the prostate regularly. Surgery or radiotherapy is used only if the tumor grows or causes symptoms – or if a man decides to do so later.

This approach is based on the fact that low-risk prostate cancer often grows very slowly or doesn't grow at all, so treatment often isn’t needed.

Medical societies in Germany recommend active surveillance:

• A PSA test every 3 to 6 months for the first two years
• Magnetic resonance imaging (MRI) scan of the prostate and up to 2 biopsies after 6 to 18 months The exact timing will depend on whether you've already had an MRI and which technique was used.
• After that, a biopsy is recommended every three years.

This approach can help many men avoid the side effects of surgery or radiotherapy. But sometimes cancer growth is detected later, and the cancer may have already spread to other parts of the body by then (metastasis). Regular check-ups are also needed for active surveillance. Among other things, tissue samples are taken (biopsy), which can be painful. In rare cases, biopsy may lead to complications such as infection.

In men with low-risk prostate cancer who are older or have other serious illnesses, the risks and distress associated with surgery or radiotherapy can outweigh the possible benefits of this treatment. Some men also say that they don’t want to have a distressing treatment. “Watchful waiting” is then an option. Doctors do not treat the cancer, only possible symptoms such as pain.

One big difference to active surveillance is that you don’t need to have bothersome check-ups in the watchful waiting approach.

Watchful waiting is mainly considered in men who are estimated to have a remaining life expectancy of less than ten years independent of the cancer. Their prostate cancer isn’t likely to grow much during that time.

Cancer cells can be removed by using radiotherapy or surgery. These procedures are associated with various side effects, though, and these can be very distressing. Sometimes they go away over time, but sometimes they remain. There are three main types of complications:

• Problems urinating: It is possible that the bladder or urethra becomes injured or inflamed. This can lead to an increased urge to urinate or a burning sensation when urinating. It can also cause problems with holding back urine (urinary incontinence). Some men will then need to use pads over the long term.
• Bowel problems: Radiotherapy can irritate other nearby organs such as the rectum. Possible effects are liquid stool or involuntary bowel movements (fecal incontinence).
• Erectile dysfunction: If the nerves responsible for the erection are damaged, erectile function may be partially or completely lost.

In addition, when inserting the pins for internal radiotherapy and removing the prostate – as with any surgical procedure – there may be general side effects such as infections or problems caused by the anesthetic.

The ProtecT study (Prostate testing for cancer and treatment trial) compared three treatment options: active surveillance, external radiotherapy and surgery to remove the prostate (prostatectomy). The men in the study were between50 and 69 years of age. They were randomly assigned to one of the three treatment groups. About two thirds of them had low-risk prostate cancer. After an average of 15 years, the results showed:

• There was no difference in mortality rate (number of deaths) between the active surveillance, radiotherapy and surgical removal groups. About 3 out of 100 men died during the 15 years in each of the three treatments.
• Men who had active surveillance had a slightly higher risk of metastases. During the 15-year period, 7 out of 100 of these men developed metastases, compared to 4 out of 100 who had radiotherapy or prostatectomy.
• Men who had surgery had a much higher risk of involuntary urination (urinary incontinence). 30 out of 100 of these men developed urinary incontinence, whereas with radiotherapy it was only 2 out of 100.
• Men who had radiotherapy or surgery had a much higher risk of erectile dysfunction. 45 out of 100 men who had their prostate removed were affected. Radiotherapy led to erectile dysfunction in 35 out of 100 men – especially in the first few months after the treatment.
• Men who had radiotherapy had a slightly higher risk of involuntary bowel movements (fecal incontinence). About 4 out of 100 men experienced this during the treatment and two years later. Men who had active surveillance or surgery did not have any bowel problems.

The ProtecT trial has several limitations: For example, the observation period has so far been restricted to 15 years. But it would be easier to compare the pros and cons of the three treatment options after 20 or more years.

The ProtecT trial also has another limitation: The check-ups that men had in the "active surveillance" group were different from the current standard approach in Germany. In the ProtecT trial, the men had a PSA test every 3 months in the first year, and then every 6 to 12 months after that. If the PSA levels were too high or if the men developed symptoms such as problems urinating, they had further tests. In Germany, doctors recommend that men who have abnormal PSA test results get regular biopsies (tissue samples taken). This is meant to increase the likelihood of finding out soon enough if the cancer progresses, but it can also be more distressing.

Despite these limitations, the ProtecT trial currently provides the best basis for making a decision about the treatment of low-risk prostate cancer.

There hasn't been enough good research on other treatments such as "high intensity focal ultrasound" (HIFU), cryotherapy (freezing) or hyperthermia treatment (using heat). Because of this, medical societies in Germany don't recommend using them in the treatment of prostate cancer, or only recommend using them for research purposes.

Men who have low-risk prostate cancer can take their time to weigh the benefits and risks of the various treatment options.

Other factors, such as the man’s age and how healthy he is overall, will play an important role in the decision too. A young and otherwise healthy man who still has many years ahead of him will probably weigh the pros and cons of the treatment options differently than an older man who has other medical problems and a shorter life expectancy.

It is best to discuss the pros and cons of the possible treatments with your doctors.

Further information on the treatment of prostate cancer is also available from the German Cancer Information Service (Krebsinformationsdienst).