Active surveillance for low-grade disease
What is done with elevated or rising PSA levels is most controversial, with lots of room for doing harm. Dramatic rises in PSA, like those of the patients I described earlier, are easy: Go right to biopsy and usually, treatment. Gleason 6 prostate cancer is likely to remain localized and indolent, and not threaten life. I work with urologists who are not aggressive and are willing to follow patients with PSA levels up to 10. Noninvasive options are available, such as fractionating the PSA (free and total) and imaging such as MRI. Genetic testing is available and can add to the evaluation of the patient’s risk.
Active surveillance has become a standard of care in monitoring patients with low-grade disease. The outcomes for survival with active surveillance are as good as radical prostatectomy.11 The goal is to be aggressive in treatment only with patients who have life-threatening disease. A collaboration among the patient, the primary care physician, and the urologist is crucial to optimizing patient outcomes.
Recommending against screening for prostate cancer is not tenable. The responsible approach is to continuously improve cancer detection and therapy to maximize good and minimize harm. This approach is available today.