The concept of active surveillance or watchful waiting today represents a valuable alternative to prostate cancer treatment. Avoiding systematic recourse to surgery or radiotherapy, first and foremost active surveillance preserves the patients’ quality of life.
Testament to this is that the majority of urology societies throughout the world have incorporated active surveillance into their national recommendations, with regard to prostate cancer care in cases of low or very low risk of progression.
The method is applicable in the following circumstances:
- Non-aggressive prostate cancer with a low probability of reducing the life expectancy of a patient.
- Any treatment, regardless of its nature, presents certain risks and the foreseeable side effects may impact upon the patient’s quality of life.
As a medium- to long-term strategy, this management system involves monitoring the development of the cancer and initiating treatment only where necessary. In other words, when the cancer has progressed and the risk/benefit ratio has tilted in favour of intervention.
The success of this protocol depends on regular monitoring of the signs of cancer progression. The patient will therefore receive periodic screening (Radiology MRI) and diagnostic tests focusing on the identified lesion: PSA test, digital rectal exam, biopsies and MRI monitoring.
This type of management system has proven clinical benefits. Among patients with prostate cancer at low risk of progression, the specific survival rate exceeds 98% after ten years of active monitoring.
The use of active surveillance
In cases of a non-aggressive cancer
According to the French Urology Association (Association Française d’Urologie – AFU), an active surveillance or watchful waiting procedure can only be implemented on the condition that the cancer is non-aggressive, which can be defined using the following criteria:
- Cancer confined to the prostate
- Isolated low-volume tumour
- Low Gleason Score < 7
- PSA level under 10
Non-radical active treatments, known as “focal therapies”, are also being explored for patients presenting aggressive lesions that are nonetheless too localised to justify radical intervention.
The importance of the patient’s age
The age of the patient is a determinant factor. As a precautionary measure, an active surveillance protocol will not be offered to men under the age of 65. This is because the risk of death is three times greater 15 years after the appearance of the first tumors.
The presence of other conditions
For a patient subject to other serious conditions, it may be advisable to opt for active surveillance even in the case of “aggressive” prostate cancer.
Of course, the decision to implement such a protocol will always be made in an informed manner by the doctor together with their patient.
Targeted biopsy monitoring
The active surveillance procedure requires precise monitoring of the development of cancerous tumours within the prostate.
At present, this essential condition can be met only by means of fusion-targeted biopsies (transrectal or transperineal approach), owing to the recording and recall capacities of previous biopsy techniques.
- The role of MRI in active surveillance for men with localized prostate cancer.- Recabal P et al. Curr Opin Urol– November 2015Curr Opin Urol – November 2015 " title="" aria-describedby="qtip-0">1
- Integrated US-MR fusion images and MR targeted biopsies. What are their role and value in the detection and follow-up of prostate cancer.- Delongchamps et al. Arch Esp Urol. April 2015Arch Esp Urol. April 2015" title="" aria-describedby="qtip-1">2
- A novel technique using three-dimensionally documented biopsy mapping allows precise re-visiting of prostate cancer foci with serial surveillance of cell cycle progression gene panel.Ukimura et al. –Prostate – June 2015 Prostate – June 2015" title="" aria-describedby="qtip-2">3
- Innovations in prostate biopsy strategies for active surveillance and focal therapy.Ukimura et al.-Curr Opin Urol – March 2011 Curr Opin Urol – March 2011" title="" aria-describedby="qtip-3">4
Over recent years, traditional screening (ultrasound and radiology MRI-US) and diagnostic methods have been supplemented by new genetic/genomic tests.
By providing additional information, these tests open up new perspectives that help doctors and patients define more accurate diagnosis and decide whether or not to proceed with active surveillance.
Additionally, psychological support gives patients the tools and resources needed to accept and adapt to living with cancer in relative peace. In some cases, patients may be reluctant to undergo active surveillance, instead preferring immediate active treatment.
The advantages of active surveillance
List of benefits for the patient to wait and watch:
- None of the risks associated with treatment (for example, the risks relating to general anaesthesia)
- None of the side effects associated with treatment (erectile dysfunction, urinary incontinence, etc.)
- Preserved quality of life under watchful waiting
- Anticipated progress of new experimental treatments
Risks and side effects
List of risks and side effects associated with an active monitoring procedure:
- Regular prostate biopsies, increasing the related risks and side effects
- Risk that the cancer progresses more quickly than expected, which may cause problems in terms of treatment. However, several studies have found that the risk remains low
- Onset of other health problems, such that certain treatments are no longer possible
KOELIS® technology for active surveillance
For over a decade KOELIS® has been assisting physicians from around the world in their routine clinical practice providing the latest technology for a patient-centered solution against prostate cancer.
The increasing number of early-detected low-risk prostate cancer leads urologists to consider alternative treatments to radical prostatectomy like active surveillance (watchful waiting). As you’ve read above, active surveillance requires follow-up biopsies repeated at defined time intervals in order to track the progression of the disease.
At KOELIS®, we’ve developed an innovative software technology providing extraordinary quality control to active surveillance. Our solution KOELIS Trinity®, a 3D TRUS/MRI and TPUS/MRI fusion guided biopsy system enables to guide, map and record the actual 3D biopsy samples for all patients. 3D biopsy maps can be reviewed at all time and discussed with patients and physicians. They can be loaded and registered with MRI to comprehensively document the disease extension and to target the next intervention. In addition, images from previous plans, exams or treatments can be fused with live ultrasound imaging for confirming treatment’s efficacy and evaluating the optimal selection and follow-up processes for men on active surveillance.
For more information, contact us.
- The role of MRI in active surveillance for men with localized prostate cancer- Recabal P et al. Curr Opin Urol – November 2015
- Integrated US-MR fusion images and MR targeted biopsies. What are their role and value in the detection and follow-up of prostate cancer.- Delongchamps et al.Arch Esp Urol. April 2015
- A novel technique using three-dimensionally documented biopsy mapping allows precise re-visiting of prostate cancer foci with serial surveillance of cell cycle progression gene panel.Ukimura et al. –Prostate – June 2015
- Innovations in prostate biopsy strategies for active surveillance and focal therapy.Ukimura et al.-Curr Opin Urol – March 2011