Active surveillance-You have to have the biopsy first.

NCCN Guidelines For Prostate Cancer Updated To Stress Careful Consideration Of Active Surveillance- Medical News Today

11 Jan 2010   

The National Comprehensive Cancer Network (NCCN) recently updated the NCCN Clinical Practice Guidelines for Oncology™ for Prostate Cancer to reflect new recommendations regarding active surveillance, also referred to as watchful waiting, for men with low risk prostate cancer.

A significant change incorporated into the updated NCCN Guidelines for Prostate Cancer is the recommendation for active surveillance and only active surveillance for many men diagnosed with prostate cancer. Men with low risk prostate cancer who have a life expectancy of less than 10 years should be offered and recommended active surveillance.

In addition, a new “very low risk” category has been added to the updated NCCN Guidelines using a modification of the Epstein criteria for clinically insignificant prostate cancer. Only active surveillance is offered and recommended for men in this category when life expectancy is less than 20 years.

“The NCCN Prostate Cancer Guideline Panel and the NCCN Prostate Cancer Early Detection Panel remain concerned about over-diagnosis and over-treatment of prostate cancer,” says James L. Mohler, MD, of Roswell Park Cancer Institute and chair of the NCCN Guidelines Panel for Prostate Cancer. “Growing evidence suggests that over-treatment of prostate cancer commits too many men to side effects that outweigh a very small risk of prostate cancer death.”

The NCCN Guidelines Panel took careful consideration, including a thorough review of evolving data, of which men should be recommended for active surveillance. The updated NCCN Guidelines now recommend active surveillance for men with very low risk prostate cancer and life expectancy estimated at less than 20 years or men with low risk prostate cancer and life expectancy estimated at less than 10 years.

“Although the NCCN Guidelines Panel stresses the importance of considering active surveillance, ultimately this decision must be based on careful individualized weighting of a number of factors including life expectancy, disease characteristics, general health condition, potential side effects of treatment, and patient preference,” notes Dr. Mohler. “It is an option that needs to be thoroughly discussed with the patient and all of his physicians which may include his urologist, radiation oncologist, medical oncologist, and primary care physician.”

The updated NCCN Guidelines stress that active surveillance involves actively monitoring the course of the disease with the expectation to intervene if the cancer progresses. Patients under active surveillance must commit to a regular schedule of follow-up, which includes a prostate exam and PSA, and which may include repeat prostate needle biopsies.

The NCCN Clinical Practice Guidelines in Oncology™ are developed and updated through an evidence-based process with explicit review of the scientific evidence integrated with expert judgment by multidisciplinary panels of physicians from NCCN Member Institutions. The most recent version of this and all the NCCN Guidelines are available free of charge at

National Comprehensive Cancer Network

My thoughts-

I have patients tell me all the time they want to “do nothing.” The problem with most who say this is that they are thinking this before the biopsy or the knowledge of prostate cancer exists. In other words, they have heard of active surveillance and the slow-growing nature of prostate cancer and are using this as an argument not to have the biopsy in the first place. You have to know the specifics of the cancer in addition to your overall medical condition and life expectancy to adequately determine if you are a candidate. In general as stated in the article above, favorable parameters of the biopsy and life expectancy of less than ten years make for a good candidate for surveillance. I might add, that for me it was not an option as I was relatively young with a long life expectancy but my mentality was not suitable in this case for doing nothing. I couldn’t just do nothing knowing that there was “something in me.”

6 Replies to “Active surveillance-You have to have the biopsy first.”

  1. I realise it is 7 years since you wrote this blog. I wonder if your thoughts about needle biopsies have changed in that time? I endured 17 cores, taken with great pain and a lot of bleeding. My personal thought is that disturbing the tumour in this way may have increased the likelihood of its spreading to other parts of my body. I do agree however, once you know its there you have to do something about it. The big question is, what? It really is a spin of the chocolate wheel.


    1. It has never been shown that biopsies spread the cancer however this is a common question and makes sense that it could happen. Johns Hopkins is the world’s leading prostate cancer institution. Their surveillance program recommends yearly biopsy. So…my thoughts are that if anybody would know about spreading cancer with a biopsy, they would.
      About you…tell me your Gleason’s score, and the other particulars of your case and what treatment if any you’ve had and stage if you know it. I’ll look at and opine. Thanks you contributing. JM

      Liked by 1 person

  2. Thank you for your response JM. I will put together some data tomorrow. I certainly value your opinion. There is some information in my blog, psa graph for example, however I appreciate that your time is valuable, so I will send you a concise summary. Kind regards, Les


  3. Following is a brief summary of my prostate cancer journey:
    Initial Diagnosis August 2008: T2 N0 M0 PSA 12, 5/8 cores positive Gleason 3+4=7 adenocarcinoma. I initially opted for EBRT and ADT. I had a 3 month Zoladex 10.8 implant but later changed my treatment choice to Radical Prostatectomy.
    Dr Greg Malone from Brisbane performed surgery November 2009. Histopathology report states Gleason 4+3=7, tertiary pattern 5. Carcinoma present in all zones, occupying 25% of gland by volume.There is prominent perineural invasion but no extra prostatic extension seen. There is invasion into left seminal vesicle and 2 positive margins.
    My recovery was good and I have had very little in the way of incontinence. I am totally impotent and never regained any erectile function.
    I had intermittent hormone therapy until early 2016 when psa began to rise suggesting hormone resistant disease. A PSMA scan revealed a single metastasis in my left hip. I posted part of the scan recently in my blog. In March 2016 I had 30 Gy in 6 sessions and my psa began to decline from c.30 to c.7 in December 2016.
    By this time I was in Canada with no access to health care. My local GP assisted me to monitor my psa and also tested for testosterone, which was undetectable. I had brought a Zoladex injection with me and still have not used it. Currently I am using some dietary and supplement measures. My last psa was 48.6 in March this year. I contacted my radiation oncologist in Newcastle NSW and he will see me in July, when I return to Australia.

    My health is excellent. I have no other serious conditions. I feel fit and have no symptoms. I am concerned about the effects of no testosterone on my muscles and bones. Any advice you can offer would be most welcome. Thank you for reading my story. Les.


    1. These will be general thoughts, as you know your doctor is the boss…having said that-I am a proponent of intermittent hormone therapy. In light of your current Psa you need to take your Zoladex and consider adding Casodex to achieve total androgen ablation. The hip finding and the rising Psa suggest that the cancer cells are active and must be reversed. I understand your concerns about testosterone but the rising Psa trumps that. There are medicines that can be given to protect your bones.
      My humble opinion is that you need to reverse the Psa with your shot and potentially add Casodex which gets the testosterone production that Zoladex doesn’t. Read about a pathological fracture…we don’t want that. I hope this helps…in many ways the treatment of your particular situation is simple…keep the Psa down. I have read your blog and admire and respect your spirit and again these are my thoughts and you should seek out a physician where you are or at home who can talk to you in person and advise. What I have said however may be used as a foundation of questions you might ask. You know what they say, “Don’t trust the internet,” I guess that includes me. JM

      Liked by 1 person

      1. Thank you for your input, it means so much to me that you care and that you read my blog. I am sure there are many people who have read your blog and gained knowledge from it. It is certainly a part of the Internet that can be trusted! I will let you know how things turn out. Thank you again, be well! Les.


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