5 minutes Adam Gaines

Low risk localised prostate cancer and active surveillance

Low Risk Localised Prostate Cancer and Active Surveillance – Statement by Prostate Scotland
Active Surveillance for low risk early prostate cancer has been in the news recently following the decision by the National Institute for Clinical Excellence recently to update their prostate cancer guidance for England and Wales. The NICE guidance sets out that men with low risk localised prostate cancer should be offered a choice of active surveillance, radiotherapy or radical prostatectomy. The guidance says that over a ten year survival period survival by men with low risk localised prostate cancer who opt for active surveillance is similar to those who have been treated with surgery or radiotherapy. The guidance however also sets out that surgery and radiotherapy reduce disease progression, by comparison with active surveillance, and are more likely to reduce the likelihood of the development of metastatic prostate cancer.

It should be noted that active surveillance is not a treatment but a management of the prostate cancer. The principle behind active surveillance is that the prostate cancer is actively monitored, so that if through the active monitoring procedure (PSA tests, DRE, scans and/or a biopsy) it is noticed that the cancer is starting to grow/progress, then the urologist is likely to recommend that treatment starts. For some men this will lead to a choice between surgery and radiotherapy. In practice the role of active surveillance as a management for low risk prostate cancer alongside the availability of radical treatments such as surgery and radiotherapy, has been increasingly offered as the appropriate first response for men with low risk localised prostate cancer in the past few years in Scotland. The new guideline from NICE effectively reflects the practice that is increasingly in effect the case across Scotland.

Many men with low risk prostate cancer opt for Active Surveillance as their choice as it can reduce the potential for side effects, and may be a way of deferring treatment, however many men also opt for the potentially greater certainty of curative treatment of surgery or radiotherapy.  It should also be noted that many men on active surveillance where their cancer progresses go on to radical treatment.

It is important that men with low risk prostate cancer are offered the choice of relevant treatments and options (subject to clinical criteria) including the option of active surveillance, and it is crucial that men are offered relevant and accessible information and support on making a choice at this challenging time in their lives.  Prostate Scotland has produced information about Early Prostate Cancer  and also about Active Surveillance .

It should be noted that the NICE guideline/advice on active surveillance only applies to low risk and (in some cases intermediate) prostate cancer and not to higher risk cancers, where radical treatment is likely to be indicated and only applies in England and Wales. Men with early/low risk prostate cancer must fit certain criteria to be eligible for active surveillance.  

Notes
1.  Active surveillance of low risk localised prostate cancer  Active surveillance is a management option suitable for some  men with low risk localised prostate cancer because some prostate cancers grow more slowly than others and are non-aggressive.  Active surveillance means that the cancer will be closely monitored, and a series of tests and checks will be regularly undertaken.  Treatment is deferred, until such times that treatment becomes necessary.  Men on active surveillance are eligible to opt out of active surveillance at any time.  As Active Surveillance is management option for prostate cancer, not a treatment and that there may be the potential that the disease could progress in the future it is important to ensure that men are able to discuss with their consultant or clinical specialist nurse about all their options, including radical therapies at the time of choice or if the cancer progress.  For further information please see https://www.prostatescotland.org.uk/wp-content/uploads/resources/Active-Surveillance-as-a-management-for-eralay-prostate-cancer-2015-1.pdf
Or https://www.prostatescotland.org.uk/wp-content/uploads/resources/Early-Prostate-Cancer-Explained-Booklet.pdf

2. Prostate cancer is the most common cancer amongst men in Scotland, with a lifetime chance of one in ten men developing it. There were over 33,258 new registrations of men with prostate cancer between 2005 and 2015 and 9,316 deaths of men in Scotland from prostate cancer during that period.[I] Encouragingly survival rates amongst men with prostate cancer have doubled over the past two decades with 80% of men with prostate cancer now surviving it[ii]. Over the past 20 years the number of men surviving prostate cancer has doubled and survival rates are now 80%.[iii] Projections by the NHS show that the diagnosis of men with prostate cancer is likely to rise by up to 35% between now and 2027.

[i] See Scottish Cancer Registry May 2017 and Cancer in Scotland, Information Services Division NHS National Services Scotland April 2017
[ii] Cancer in Scotland: ISD, NHS National Services Scotland, September 2011
[iii] See Scottish Cancer Registry May 2016 and Cancer  Incidence in in Scotland (2014), and Information Services Division NHS National Services Scotland  November 2015