The Tribune

By Dr GREGGORY PINTO

Prostate cancer will affect one in six men in their lifetime.

Early detected low-volume, low-grade, early-stage prostate cancer has an excellent cure rate of 97 to 98 percent 10 years after the initial curative treatment.

Urologists seek the trifecta for prostate cancer curative treatment: complete lifelong cure for the disease itself, with the preservation of erectile function and maintaining urinary continence post-treatment.

There are multiple treatment modalities available for the cure of prostate cancer, including radical prostatectomy surgery that may be performed open, laparoscopic or with the use of the da Vinci robot; various forms of external beam radiotherapy; low dose and high dose brachytherapy; HIFU (High intensity focused ultrasound), cryotherapy, or a required combination of these modalities. Androgen deprivation therapy may also be employed short term with one of these curative modalities.

All curative treatments for prostate cancer have varying risks of side effects that include erectile dysfunction and urinary incontinence/ leak.

Active surveillance if employed to the correct patient with prostate cancer, can delay the potential exposed risk to these unfortunate side effects associated with the curative treatments for prostate cancer.

Active surveillance aims to lead to the preservation of a high quality of life for men afflicted with prostate cancer, without posing a risk to the advancement of the disease beyond the curvature stage.

Active surveillance should not be confused with watchful waiting.

Watchful waiting is a management option involving observation for advanced prostate cancer or for prostate cancer diagnosed in men who are not expected to live ten years.

Watchful waiting involves observation for symptoms of advanced prostate cancer, with the treatment of the symptoms such as bone pain or obstructive urinary symptoms and does not involve curative treatment.

Active surveillance is a well established and effective management option for early, clinically insignificant prostate cancer.

Active surveillance has 20 years plus as an evidence-based, safe and effective management modality for low volume, early stage, low risk prostate cancer.

Governing urology bodies throughout the world, such as the European Association of Urology and the American Urology Association historically have made prostate cancer active surveillance an accepted and verified beneficial method of managing early low risk prostate cancer patients.

Approximately 30 percent of detected prostate cancers in most First World countries are of no clinical significance to the patient at the time of diagnosis.

Active surveillance is based on the premise that some low-volume, early-stage prostate cancers are of no immediate health risk to the patient.

Out of the 10 most common cancers in the world, prostate cancer is the only one that allows the highly beneficial method active surveillance before the required need to act and cure the cancer.

Active surveillance involves closely monitoring a patient until such time that the prostate cancer has become clinically significant in terms of an upstaging in volume, pathological stage or grade of the prostate cancer.

Active surveillance does not mean no treatment for prostate cancer, but treating prostate cancer only when the prostate cancer has clinical significance and poses a risk to the patient.

The criteria for the active surveillance of prostate cancer is strict and investigations such as Magnetic Resonance Imaging is becoming the mainstay in the selection process for patients to be placed in the management arm of active surveillance.

Patients may have the great benefit of not requiring curative treatment for prostate cancer potentially for several years.

The criteria to be eligible for prostate cancer active surveillance includes having organ confined disease and a PSA blood test with a value less than 10 ng/ml and a PSA density of less than 15 percent, a Gleason pathology of 6 out of 10, with no more than 3 out of 12 positive prostate biopsies cores that must be present in only one lobe of the prostate and have less than 50 percent cancer involvement of each core , and clinically impalpable or minimally palpable prostate cancer.

After 20 years plus of robust data and long term, multi-centre trials, active surveillance continues to be supported as a safe, internationally accepted management method of clinically insignificant prostate cancer.

Active surveillance for early and low-volume, clinically insignificant prostate cancer requires a certain mindset for the patient. A man with a diagnosis of prostate cancer is asked to not seek immediate curative treatment but to receive surveillance until the disease becomes clinically significant and then opt for cure.

For one in four men the uncertainty and anxiety while on active surveillance for prostate cancer will lead to them requesting definitive therapy within three years of diagnosis, even when the cancer has not progressed.

The Bahamas has a population that is predominantly of African ancestry and there is unfortunately a high rate of obesity, and both of these Bahamian male dynamics places us as a group at a higher risk of more aggressive prostate cancer.

The earliest pathological grade of prostate cancer, Gleason 6 out of 10, has found to be more aggressive in black men than their other racial counterparts.

Active surveillance however does still hold an important role in prostate cancer management in the Bahamas, like all other predominantly black countries.

The future of active surveillance for prostate cancer will involve genetic testing to identify clinically insignificant disease that appears indolent but has aggressive potential.

Bahamian men, do not let prostate cancer negatively affect your life in terms of longevity or quality of life. A routine annual PSA blood test should commence at the age of 40 years old.

Early detection leads to early cure. Early detection may require no immediate treatment of prostate cancer, with many potential years of active surveillance.

Visit your urologist for compassionate, comprehensive and confidential care.

• Dr Greggory Pinto is a Bahamian urologist who has trained in South Africa, Germany, France and India. He is a member of the European Association of Urologists. Dr Pinto can be reached at Urology Care Bahamas at the Surgical Suite, Centreville Medical Centre, Collins Avenue and Sixth Terrace. Call 326 1929, e-mail welcome@urologycarebahamas.com, or visit www.urologycarebahamas.com.