What is the recommended management approach for patients with low-risk prostate cancer?

Management of Low-Risk Prostate Cancer

For patients with low-risk prostate cancer, active surveillance is the recommended management approach as it avoids unnecessary treatment side effects while maintaining excellent cancer-specific survival rates. 1

Risk Stratification

Low-risk prostate cancer is defined as:

• Clinical stage T1-T2a
• Gleason score ≤6 (ISUP grade 1)
• PSA <10 ng/mL

Active Surveillance Protocol

Active surveillance involves regular monitoring with the following components:

• PSA testing: Every 3-6 months 1
• Digital rectal examination (DRE): Every 6-12 months 1
• Confirmatory biopsy: Within 6-12 months of diagnosis 1
• Subsequent biopsies:
  • Every 12-18 months for the first 2-3 years
  • Then every 2-3 years if stable 1
• Multiparametric MRI: Consider at baseline and periodically (every 2 years) to improve risk stratification 2, 3

Advantages of Active Surveillance

• Avoids side effects of definitive therapy (erectile dysfunction, urinary incontinence, bowel dysfunction)
• Maintains quality of life and normal activities
• Reduces unnecessary treatment of indolent cancers
• Excellent cancer-specific survival (>97% at 10 years) 2

Indicators for Intervention During Active Surveillance

Consider definitive treatment if any of the following occur:

• Gleason grade progression (appearance of pattern 4 or 5)
• Increase in number of positive cores or extent of cancer in cores
• PSA doubling time <3 years
• Clinical progression on DRE
• Patient preference/anxiety 1, 4

Alternative Treatment Options

For selected low-risk patients who prefer definitive treatment or have high probability of progression:

1. Radical Prostatectomy:

   • Offers definitive treatment but associated with risks of erectile dysfunction (up to 80%) and urinary incontinence (up to 49%) 1

2. External Beam Radiation Therapy:

   • Delivered using conformal techniques to minimum target dose of 70 Gy
   • ADT should NOT be added for low-risk disease 1

3. Brachytherapy:

   • Appropriate option for monotherapy in low-risk disease
   • Similar long-term survival to radical prostatectomy with potentially fewer side effects 1

Important Considerations and Pitfalls

• Patient selection is critical: Ensure accurate staging with systematic biopsy (minimum 8-10 cores) 1
• Patient education: Many patients overestimate the survival benefit of immediate treatment; ensure they understand the excellent prognosis of low-risk disease 1
• Psychological impact: Some patients experience anxiety with active surveillance; regular counseling may be beneficial 1
• Special populations: African American men and those with BMI >35 kg/m² may have higher risk of reclassification to higher-risk disease on surveillance biopsies 3
• Avoid unnecessary imaging: Abdominal/pelvic CT and bone scans are not recommended for asymptomatic low-risk patients 1

Follow-up After Treatment (if chosen)

• After radical prostatectomy: Monitor with sensitive PSA assay; consider salvage radiotherapy for PSA failure
• After radiation therapy: Regular PSA monitoring for biochemical failure

Active surveillance represents a paradigm shift from immediate treatment to careful monitoring, allowing patients to avoid or delay the side effects of definitive therapy while maintaining excellent cancer control rates 5.