DEAR DR. ROACH: I am a 66-year-old white male who is active and relatively healthy. I have recently been diagnosed with prostate cancer. One blood test showed a PSA level of 13 ng/mL, and a second was 17 ng/mL. So, I underwent a biopsy, which showed adenocarcinoma with a Gleason score of 6 (3+3), grade group 1. The tumor was measured to be 0.4 cm in length, with 5% of the core involved.

A second area of the tumor at the right base had the same Gleason score and grade. This one had a length of 0.13 cm, with 10% of the core involved. Since these were considered tiny tumors, surgery was not recommended for me at the time. Instead, I was advised to wait, watch, and do PSA blood tests every four to six months.

Do you consider the cancer measurements to be small, thus making the “observation only” protocol correct? — B.A.

ANSWER: Prostate cancer can be very aggressive and is responsible for over 35,000 deaths per year. However, it can also be very indolent, with many cases destined to never cause any symptoms during a person’s lifetime. Still, many cases of prostate cancer fall in between these markers, so determining the level of necessary treatment is sometimes challenging.

Of the factors related to prostate cancer, the size of the tumor, the pathology and molecular characteristics of the tumor, and the PSA level are all useful in predicting the aggressiveness of the cancer and the recommended treatment. We don’t want to unnecessarily recommend aggressive treatment, since it has the potential for serious side effects. On the other hand, we don’t want to let a dangerous cancer grow untreated.

In your case, you have two very small tumors, the size of which puts you at the lowest risk. You have very favorable pathology; a Gleason score of 6 is very good news. If your PSA level were less than 10 ng/mL, you would have been at the lowest possible risk. However, your PSA is between 10-20 ng/mL, so you are in the “favorable intermediate risk” group.

In this group, active surveillance is a very reasonable option. We prefer this phrase to “watch and wait,” since your doctors will be watching you carefully and will be ready to put you into a higher risk category if your PSA level goes up or the tumor grows. It is likely that you will be followed up with a prostate MRI to look for growth in the tumor and will likely receive another biopsy if the MRI shows that the tumor is growing.

Some men in your situation will choose surgery, radiation or medication to lower testosterone. Some experts recommend molecular testing of the tumor to help stratify treatment, while other experts do not feel that the evidence is strong enough to use these tests.

While I can’t tell you what to do, I can say that you are at a low risk for the cancer to spread by the next time they do an evaluation. But there is some risk, which would be minimized by seeking definitive treatment now. Your urologist has a great deal of expertise, and by working together, you can come up with the best plan for you.

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