What is Active Surveillance for Prostate Cancer: Purpose, Procedure, Results, Preparation & Costs in India

Prostate cancer is a significant health concern for men worldwide, and India is no exception. The good news is that not all prostate cancers require immediate, aggressive treatment. For men diagnosed with low-risk prostate cancer, a management strategy called active surveillance offers a way to closely monitor the disease without rushing into potentially life-altering treatments. This blog post aims to provide a comprehensive overview of active surveillance for prostate cancer, specifically tailored to the context of Indian patients. We'll delve into what it is, why it's performed, who is a good candidate, the steps involved, potential risks, and the costs associated with it in India.

What is Active Surveillance for Prostate Cancer?

Active surveillance is a management strategy for men with low-risk prostate cancer. Instead of undergoing immediate treatment like surgery or radiation, which can have significant side effects, men on active surveillance are closely monitored with regular testing. The goal is to detect any signs of cancer progression and intervene with treatment only if and when it becomes necessary. This approach aims to avoid or delay aggressive treatments and their associated side effects, preserving quality of life for as long as possible. Think of it as a proactive, vigilant approach to managing the cancer rather than immediately eradicating it.

Why is Active Surveillance Performed?

The primary goal of active surveillance is to avoid overtreatment. Many men diagnosed with low-risk prostate cancer have slow-growing tumors that may never cause any problems during their lifetime. Aggressive treatments like surgery or radiation can lead to side effects such as:

Incontinence: Difficulty controlling urination.
Erectile dysfunction: Difficulty achieving or maintaining an erection.
Bowel problems: Changes in bowel habits.

Active surveillance seeks to strike a balance. It provides a way to:

Monitor Cancer Progression: Closely track the cancer's behavior through regular testing.
Delay or Avoid Treatment: Postpone or even completely avoid aggressive treatments and their side effects if the cancer remains stable.
Maintain Quality of Life: Help patients maintain a better quality of life by avoiding or delaying treatments and their side effects.
Intervene When Necessary: Allow for timely intervention with definitive treatment if the cancer shows signs of progression.

Conditions and Indications:

Active surveillance is typically considered for men who meet specific criteria, indicating a low risk of cancer progression. These criteria often include:

Low PSA Levels: A Prostate-Specific Antigen (PSA) level below 10 ng/mL is often a key indicator that the cancer may be low-risk.
Low Gleason Score: A Gleason score of 6 or less on biopsy, which indicates a less aggressive cancer cell pattern.
Small Tumor Volume: The cancer is confined to a small area of the prostate.
Limited Number of Positive Biopsy Cores: Only a small number of biopsy samples show cancer.

It's crucial to understand that active surveillance is not a "one-size-fits-all" approach. The decision to pursue active surveillance should be made in consultation with a urologist and based on a thorough evaluation of individual circumstances.

Who Needs Active Surveillance? (Patient Profiles)

While the specific criteria for active surveillance are determined by a urologist, here are some general patient profiles that may be suitable candidates:

Older Men with Co-existing Health Conditions: Men with significant health issues that might make them poor candidates for surgery or radiation may benefit from active surveillance. The focus is on maintaining quality of life and avoiding unnecessary risks.
Men with Very Low-Risk Prostate Cancer: Men diagnosed with small, slow-growing tumors that are unlikely to cause problems in their lifetime are often good candidates for active surveillance.
Men Who Prioritize Quality of Life: Men who are particularly concerned about the potential side effects of treatment and prioritize maintaining their quality of life may opt for active surveillance.
Men Who Understand the Risks and Commitments: Active surveillance requires a commitment to regular monitoring and follow-up appointments. Patients must understand the potential risks and be willing to adhere to the monitoring schedule.

It's important to remember that age alone is not a deciding factor. A younger man with very low-risk disease may also be a suitable candidate, particularly if they are carefully monitored. The key is to have a thorough discussion with your doctor and weigh the potential benefits and risks of active surveillance versus immediate treatment.

Preparation for Active Surveillance (India-Specific Tips)

Before starting active surveillance, thorough preparation is essential to establish a baseline understanding of the cancer and ensure the patient is well-informed and prepared for the monitoring process. Here are some India-specific tips to consider:

Diagnosis Confirmation:
- Review Biopsy Results: Carefully review your biopsy report with your urologist. Understand the Gleason score, the percentage of positive cores, and any other relevant details.
- PSA Levels: Discuss your PSA levels and any recent trends with your doctor.
- Overall Health Assessment: Ensure your doctor has a complete picture of your overall health, including any other medical conditions you have.
Baseline Testing:
- Initial PSA Blood Tests: Establish a baseline PSA level to track changes over time.
- Biopsies: Confirm the initial diagnosis and assess the aggressiveness of the cancer.
- Imaging Studies: Discuss the need for imaging studies like MRI with your doctor. They may recommend Multiparametric MRI (MP-MRI) only in a patient with elevated PSA and negative DRE.
Find a Urologist Experienced in Active Surveillance: Not all urologists are equally experienced with active surveillance. Seek out a urologist who is knowledgeable about this approach and has a track record of successfully managing patients on active surveillance.
Understand the Monitoring Schedule: Discuss the frequency of PSA tests, digital rectal exams (DREs), biopsies, and imaging studies with your doctor. Make sure you are comfortable with the proposed schedule and understand the rationale behind it.
Address Anxiety and Concerns: It's normal to feel anxious about not undergoing immediate treatment. Talk to your doctor about your concerns and explore ways to manage anxiety, such as support groups or counseling.
Financial Planning: Understand the costs associated with active surveillance, including regular check-ups, PSA tests, imaging, and potential biopsies. Explore insurance coverage options and plan your finances accordingly. (More on costs later in this blog).
Consider a Second Opinion: Getting a second opinion from another urologist can provide additional reassurance and ensure you are making the best decision for your individual circumstances.
Family Support: Discuss your decision with your family and involve them in the process. Having a strong support system can be invaluable during active surveillance.
Document Everything: Keep a record of your PSA levels, biopsy results, and any other relevant information. This will help you track your progress and communicate effectively with your doctor. Apps like Ayu (more on this later) can help you store your results and track them over time.

Procedure: Step-by-Step Guide to Active Surveillance

Active surveillance involves a structured monitoring plan designed to detect any signs of cancer progression. Here's a step-by-step guide to the procedure:

Regular Follow-up Appointments: These appointments are typically scheduled every three to six months. During these visits, your urologist will review your PSA levels, discuss any symptoms you may be experiencing, and perform a digital rectal exam (DRE).
PSA Testing: Regular blood tests are conducted every 3-6 months to monitor Prostate-Specific Antigen (PSA) levels. A rising PSA level can be an early indicator of cancer progression.
Digital Rectal Exams (DRE): A physical examination is performed to assess the prostate's size and texture. Changes in the prostate can be a sign of cancer growth.
Repeat Biopsies: Periodic biopsies are performed, typically every 1-3 years, to evaluate the cancer cells and ensure the cancer remains low-risk. Biopsies are crucial for determining if the Gleason score has changed, indicating a more aggressive cancer.
Imaging Studies: MRI may be recommended if there are significant changes in PSA levels or biopsy results. Multiparametric MRI (MP-MRI) can provide detailed images of the prostate and help identify areas of concern. These are generally recommended only in a patient with elevated PSA and negative DRE.
Decision-Making: Based on the results of these tests, your urologist will assess whether the cancer is stable, progressing, or requires further investigation.
Treatment Considerations: If the cancer shows signs of progression, your urologist will discuss treatment options with you. These options may include surgery, radiation therapy, or other therapies.
Continued Monitoring: Even after starting treatment, you will continue to be monitored to assess the effectiveness of the treatment and detect any signs of recurrence.

Understanding Results: What Do They Mean?

The results of the various tests performed during active surveillance are crucial for determining whether the cancer is stable or progressing. Here's a breakdown of what the results might indicate:

Stable PSA Levels: Consistently low and stable PSA levels are a positive sign, suggesting that the cancer is not growing rapidly.
Rising PSA Levels: A significant increase in PSA levels over time may indicate cancer progression. However, it's important to note that PSA levels can fluctuate for various reasons, such as infection or inflammation. Your urologist will consider the overall trend and other factors before making any decisions.
Stable Biopsy Results: Consistent biopsy results with a Gleason score of 6 or less suggest that the cancer remains low-risk.
Upgrading on Biopsy: An increase in the Gleason score on biopsy indicates that the cancer has become more aggressive and may require treatment. One study in India showed a 50% likelihood of upstaging or upgrading in Indian males with low-risk prostate cancer eligible for active surveillance. This highlights the importance of careful monitoring and repeat biopsies.
Changes on Imaging Studies: Imaging studies like MRI can reveal changes in the size or appearance of the prostate, which may indicate cancer growth or spread.

It's crucial to discuss the results of all tests with your urologist and understand what they mean in the context of your individual situation. Don't hesitate to ask questions and seek clarification if you are unsure about anything.

Risks and Side Effects of Active Surveillance

While active surveillance aims to avoid the side effects of immediate treatment, it's important to be aware of the potential risks and side effects associated with this approach:

Anxiety: Some men may experience anxiety due to not undergoing immediate treatment. The uncertainty about the cancer's future and the need for regular monitoring can be stressful.
Frequent Medical Appointments: Active surveillance requires a commitment to regular check-ups and tests, which can be time-consuming and disruptive to daily life.
Cancer Growth: There is a possibility that the cancer could grow and spread while under surveillance, potentially missing the window for effective treatment.
Fewer Treatment Options: If the cancer spreads, treatment options may become more limited and drastic.
Upstaging or Upgrading: As mentioned earlier, studies suggest that prostate cancer may be more aggressive in some Asian countries like India. One study found a 50% likelihood of upstaging or upgrading in Indian males with low-risk prostate cancer, suggesting that active surveillance decisions should be made carefully.
Regret: Some men may later regret choosing active surveillance if their cancer progresses and requires more aggressive treatment.

It's important to weigh these risks against the potential benefits of avoiding immediate treatment and discuss them thoroughly with your urologist.

Costs in India

The cost of active surveillance for prostate cancer in India can vary depending on several factors, including:

Hospital: Private hospitals typically charge more than public hospitals.
City: Costs can vary depending on the city. Metropolitan cities like Mumbai and Delhi tend to have higher healthcare costs.
Specific Tests Required: The frequency and type of tests required will influence the overall cost.

Generally, the average cost of active surveillance for prostate cancer in India can range from ₹15,000 to ₹1,00,000 per year. This includes:

Regular Check-ups: Consultation fees with the urologist.
PSA Tests: Costs for regular PSA blood tests.
Imaging: Costs for MRI or other imaging studies.
Biopsies: Costs for periodic biopsies.

The Urological Society of India guidelines emphasize that suitability for active surveillance should consider the patient's financial condition and access to healthcare facilities. It's important to discuss the costs with your doctor and explore insurance coverage options. Several health insurance policies in India cover cancer treatment, but it's essential to check the specific terms and conditions of your policy to understand the coverage for active surveillance.

How Ayu Helps

Managing prostate cancer and active surveillance can be overwhelming, but Ayu is here to simplify the process. Ayu is an Indian medical records app designed to help you take control of your health information. Here's how Ayu can assist you with active surveillance:

Store Your Results: Securely store all your medical records, including PSA levels, biopsy reports, imaging results, and doctor's notes, in one convenient place.
Track Your Progress Over Time: Visualize your PSA trends and other key metrics over time with easy-to-understand graphs and charts. This helps you and your doctor monitor your progress and identify any potential issues early on.
Share Your Records Easily: Share your medical records with your urologist or other healthcare providers quickly and securely via QR code. This ensures that your doctors have access to the most up-to-date information, facilitating better communication and decision-making.

Ayu empowers you to be an active participant in your healthcare journey, providing you with the tools you need to manage your prostate cancer effectively.

Frequently Asked Questions (FAQ)

Here are some frequently asked questions about active surveillance for prostate cancer:

Q1: Is active surveillance the same as doing nothing?

No, active surveillance is not the same as doing nothing. It involves close monitoring of the cancer with regular testing and follow-up appointments. The goal is to detect any signs of progression and intervene with treatment only if and when it becomes necessary.

Q2: What happens if my cancer progresses while on active surveillance?

If the cancer shows signs of progression, your urologist will discuss treatment options with you. These options may include surgery, radiation therapy, or other therapies. The goal is to intervene with treatment before the cancer spreads beyond the prostate.

Q3: How often will I need to have PSA tests and biopsies?

The frequency of PSA tests and biopsies will depend on your individual circumstances. Typically, PSA tests are performed every 3-6 months, and biopsies are performed every 1-3 years. Your urologist will determine the most appropriate schedule for you.

Q4: What are the alternatives to active surveillance?

The alternatives to active surveillance include immediate treatment with surgery or radiation therapy. These treatments aim to eradicate the cancer but can also have significant side effects.

Q5: Is active surveillance suitable for all men with prostate cancer?

No, active surveillance is typically only suitable for men with low-risk prostate cancer. Men with more aggressive cancers may require immediate treatment.

Q6: Can I change my mind and choose treatment later if I start on active surveillance?

Yes, you can change your mind and choose treatment later if you start on active surveillance. However, it's important to discuss the potential risks and benefits of delaying treatment with your urologist.

Q7: Does active surveillance affect my life insurance?

Having prostate cancer may affect your life insurance premiums. It's important to disclose your diagnosis to your insurance company and discuss the potential impact on your policy.

Q8: How do I find a urologist experienced in active surveillance in India?

You can ask your primary care physician for a referral to a urologist experienced in active surveillance. You can also search online for urologists in your area who specialize in prostate cancer and active surveillance. Look for urologists who are affiliated with reputable hospitals and have a track record of successfully managing patients on active surveillance.

Q9: Will I still be able to have a normal sex life on active surveillance?

Active surveillance should not directly affect your sex life. However, the anxiety associated with having prostate cancer may affect your sexual function. If you experience any sexual problems, talk to your doctor.

Q10: Are there any lifestyle changes I can make to slow the progression of prostate cancer?

While there is no guarantee that lifestyle changes can slow the progression of prostate cancer, some studies suggest that a healthy diet, regular exercise, and maintaining a healthy weight may be beneficial. Talk to your doctor about lifestyle changes that may be appropriate for you.

Active surveillance is a valuable management strategy for men with low-risk prostate cancer. By understanding the purpose, procedure, risks, and costs associated with active surveillance, you can make an informed decision about your healthcare. Remember to consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment. And remember, Ayu is here to help you manage your medical information and empower you to take control of your health.

What is Active surveillance for prostate cancer: Complete Guide for India