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When a man has Gleason 6 prostate cancer of low volume, it is difficult to know if it is safe to do nothing. For many men it is, but which ones? That is a question that is a hot topic lately. It is very common recently to take 12 prostate biopsy specimens to sample the prostatic tissue for cancer when a patient has an elevated PSA. In one protocol consideration is given to active surveillance if the examination of the specimen shows Gleason 6 or less, positive biopsy in only two samples, and less than 20% malignancy in those two cores.
How active surveillance is done optimally is still debated. It is reasonable to re-check PSA every 3 to 6 months and to perform a biopsy annually for the first few years to ensure that the cancer does not spread rapidly or exceed the parameters for active surveillance. The option of active surveillance will be offered more and more in the coming years to prevent treating men who might never be bothered by a low grade cancer. If it never bothers the man, why treat it? But we have to be careful not to miss an important cancer that will cause harm.