Predicting low-risk prostate cancer

Active surveillance is a popular option for men with low-risk prostate cancer, defined as a tumor that is confined to the prostate gland and unlikely to grow or spread. It involves monitoring prostate-specific antigen (PSA) levels in the blood for changes and having regular digital rectal exams to look for abnormal areas on your prostate.

During active surveillance, you have a PSA test and a digital rectal exam every six months and prostate biopsies approximately every other year. If your PSA level rises, your doctor will likely recommend a prostate MRI or an immediate prostate biopsy to see if the cancer has become more aggressive. If so, you and your doctor can decide whether to continue with active surveillance and have another biopsy six months or a year later, or move ahead to treatment, such as radiation, hormonal therapy, or surgery.

What are the odds?What risk percentages from the calculators are considered “good”? It varies from person to person, and depends on multiple factors besides a number — like age, other health issues, and a person’s risk tolerance, according to Dr. Andrew Wagner, a urologic oncologist at Harvard-affiliated Beth Israel Deaconess Medical Center. “Some men may be fine with anything less than 50%, while others want less than 10%,” he says. “In general, we have found that if the risk of cancer progression is less than 20%, most men are comfortable continuing with active surveillance.”

A popular choice

Active surveillance is popular because it doesn’t require any immediate treatment and is often just as safe (or safer) than starting treatment right away. Still, the approach has its downside, such as the potential for wait-and-see anxiety, the necessity for repeated PSA tests (which are not always definitive), and the pain and risk of repeated biopsies.

Two newly created online calculators could help with these issues. They estimate how likely is it that low-risk prostate cancer will progress and invites a more nuanced approach to surveillance regimens.

“With this information, men can have a conversation with their doctor about how they may want to approach their active surveillance strategy moving forward,” says Dr. Andrew Wagner, a urologic oncologist with the Cancer Center at Harvard-affiliated Beth Israel Deaconess Medical Center.

Punching numbers

The two calculators were developed by researchers as part of the Prostate Active Surveillance Study (PASS). (You can find both at They should only be used by men who have had a least one prostate biopsy. The calculators use the results of subsequent biopsies done during surveillance, along with other measures, such as

  • age
  • body mass index
  • PSA levels
  • prostate volume (higher volume is linked with a higher risk or cancer)
  • time since prostate cancer diagnosis, in years

Both calculators rely heavily on how many biopsy samples were taken, how many of the samples showed cancer and the cancer aggressiveness score of the positive biopsies (called the Gleason score). Although the calculators have some differences, both of them provide a percentage chance that the next biopsy will or will not show features of a more aggressive form of prostate cancer. This information can help a man and his doctor decide to stick with the current plan, wait longer to have the next biopsy, or begin cancer treatment now.

Using the information

The calculators have been shown to be effective. A study published online Aug. 27, 2020, by JAMA Oncology applied the calculators to 533 men with low-risk prostate cancer who followed active surveillance. The investigators found that the results helped to better tailor the approach to the men’s specific risks.

“Therefore, men can be monitored with less intensity and hopefully fewer biopsies and less anxiety,” says Dr. Wagner.

Keep in mind that the calculators offer only an estimated outcome. For instance, a 10% chance your cancer will get upgraded by the time of your next biopsy or over the next four years is considered relatively low.

“But that doesn’t mean your cancer won’t become more aggressive,” says Dr. Wagner. “It just means you could consider skipping your biopsy and waiting longer to see if you need to begin treatment.”

Men are encouraged to ask their doctors to help them work through the PASS calculators. Alternatively, they can use the calculators themselves, provided they have the necessary information.

Bible verses for today’s meditation and inspiration: Matthew E. McLaren

And so we know and rely on the love God has for us. God is love. Whoever lives in love lives in God, and God in them. 1 John 4:16 NIV

Be completely humble and gentle; be patient, bearing with one another in love. Ephesians 4:2 NIV

We love because He first loved us. 1 John 4:19 NIV

Above all, love each other deeply, because love covers over a multitude of sins. 1 Peter 4:8 NIV

I pray that out of his glorious riches he may strengthen you with power through his Spirit in your inner being, so that Christ may dwell in your hearts through faith. And I pray that you, being rooted and established in love. Ephesians 3:16-17 NIV

And now these three remain: faith, hope and love. But the greatest of these is love. 1 Corinthians 13:13  NIV

Love must be sincere. Hate what is evil; cling to what is good. Romans 12:9 NIV

If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have a faith that can move mountains, but do not have love, I am nothing. 1 Corinthians 13:2 NIV

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