Do I still have cancer? This is a question one of my favorite patients has begun asking me, five years after I diagnosed him with prostate cancer. In the intervening time, he hasn’t had his prostate removed. He hasn’t had external beam radiation, radioactive “seeds,” or cryotherapy. Since his prostate cancer was not aggressive looking under the microscope (it was Gleason 6, a number that designates it as good risk), his PSA was low, and his prostate felt normal, we decided to follow him with an Active Surveillance.
Actually, it would be inaccurate to say “we” decided. He decided. It’s not that easy to look at a young, healthy guy and say,”you have prostate cancer; let’s watch it.” We are of course worried that the prostate cancer could leave the prostate, spreading to bone or other organs in the body and growing there. It can cause pain, fracture bones, put pressure on nerves and the spinal chord, cause anemia, weight loss, and death. But, most men are diagnosed with prostate cancer long before this, and they feel healthy. There is a group of men who we can diagnose with prostate cancer who will grow old, never suffering the ill effects of prostate cancer. Presumably, they would have good risk prostate cancer, a low PSA, a prostate that doesn’t feel hard or nodular. And they would have a low volume of prostate cancer. My patient had a “12 core” biopsy – meaning biopsies taken from 12 spots in the prostate. Only 1/12 showed prostate cancer, and it was present in less than 5% of that core. That’s the guy we worry about over treating. If you look at all they guys like Michael, some of them will make it through their entire life without feeling the ill effects of prostate cancer. Some won’t. This is the group that likely “blurs” the results of our prostate cancer screening, and makes people wonder if looking for prostate cancer causes more harm than good (but that’s a different subject). Michael got a second opinion from a doctor I respect, and we embarked upon a program of Active Surveillance. He decided he was more concerned about risks and side effects from radiation or surgery than the cancer. This meant we would biopsy him every 6 months at first, then every year. We would follow his exam and PSA. If things got worse – if he “progressed” to Gleason 7, or an abnormal rectal exam, or a consistently rising PSA, or a higher volume, we could consider treating him. He has faired well. His PSA is not above his initial level, and his exam is still normal. Most importantly, he had one biopsy early on that showed small volume, good risk disease, but all the others showed no cancer at all. Hence the question: “Do I still have cancer?” And more recently, “Is there a point at which I can stop having biopsies?”
Those are great questions. I told him that I would always consider him to have prostate cancer. This is based upon my understanding of the biology of tumors – cancer cells are not known to spontaneously disappear. But the time period over which the changes required for progression is variable, and may be longer than his lifetime. The second question – can we stop the biopsies – has go to be answered “no,” because the real answer is “I don’t know yet.”. Michael and I have had many discussions about active surveillance. One point I am always careful to bring up is that the whole idea of active surveillance is new.