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

Management of Low-Risk Prostate Cancer

Active surveillance is strongly recommended as the primary management strategy for patients with low-risk prostate cancer. 1

Risk Classification for Prostate Cancer

Low-risk prostate cancer is defined as:

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

Very low-risk prostate cancer includes additional criteria:

• Clinical stage T1c
• Presence of disease in fewer than 3 biopsy cores
• ≤50% prostate cancer involvement in any core
• PSA density <0.15 ng/mL/g 1

Active Surveillance Protocol

Active surveillance involves a structured monitoring program:

• PSA testing every 3-6 months 1
• Digital rectal examination (DRE) every 6-12 months 1
• MRI before confirmatory biopsy if not performed before initial biopsy 1
• Confirmatory biopsy within 6-12 months of diagnosis 1
  • Both targeted biopsy (of any PI-RADS ≥3 lesion) and systematic biopsy should be performed 1
  • If upfront MRI with systematic and targeted biopsies was already performed, confirmatory biopsies may not be necessary 1
• Repeat biopsies at least once every 3 years for 10 years 1
• More rigorous follow-up for younger men 1

Indications for Intervention

Consider switching to active treatment if:

• PSA progression 1
• Change in DRE or MRI findings (requires repeat biopsy before proceeding to active treatment) 1
• Biopsy showing:
  • Primary Gleason grade 4 or 5 1
  • Greater number of positive cores or greater extent of cancer in cores 1
  • Cribriform or intraductal histology (these patients should be excluded from active surveillance) 1
• PSA doubling time <3 years 1

Outcomes of Active Surveillance

• Prostate cancer-specific mortality is only 2.4% at 10 years for low-risk patients on active surveillance 1
• Quality-adjusted life expectancy is highest with active surveillance (11.07 QALYs) compared to brachytherapy (10.57 QALYs), IMRT (10.51 QALYs), and radical prostatectomy (10.23 QALYs) 2
• Treatment is associated with urinary, sexual, and bowel dysfunction while only enhancing quality-adjusted survival of low-risk patients by 1.2 months 1
• Long-term studies show cancer-specific mortality rate of only 3% at 10-15 years 3

Alternative Treatment Options

If active treatment is chosen despite low risk (not recommended for most patients):

1. Radical Prostatectomy:

   • Consider only for patients with life expectancy >10 years 1
   • Associated with higher rates of erectile dysfunction (80% vs 45%) and urinary leakage (49% vs 21%) compared to observation 1

2. Radiation Therapy:

   • External beam radiation therapy using conformal techniques 1
   • Brachytherapy is an option for monotherapy in low-risk patients 1
   • For low-risk disease, ADT should not be added 1

3. Brachytherapy:

   • Viable option for patients with good urinary function 1
   • Similar long-term survival to radical prostatectomy with less chronic urinary symptoms and erectile dysfunction 1

Common Pitfalls in Management

• Overtreatment: About 55% of low-risk patients receive unnecessary treatment 1
• Provider bias: 93% of urologists recommend surgery while 72% of radiation oncologists recommend radiotherapy for the same patient 1
• Patient misunderstanding: More than half of patients significantly overestimate the survival benefit of treatment 1
• Inadequate monitoring: Poor adherence to active surveillance protocols can lead to missed progression 1
• Inappropriate patient selection: Patients with cribriform or intraductal histology should be excluded from active surveillance 1
• Unnecessary biopsies: 79-90% of biopsies during active surveillance do not lead to reclassification 4

Special Considerations

• Watchful waiting (less intensive monitoring without curative intent) is appropriate for patients with life expectancy <10 years 1
• Patients should be informed that active surveillance maintains the window of curability while avoiding treatment side effects 1
• Regular follow-up is essential - approximately 30% of patients initially diagnosed with low-risk disease are found to have higher-risk disease on systematic biopsy during follow-up 3