Watch and wait. The practice is still strange when it comes to cancer, but for some tumors, such as prostate, kidney and breast, the concept of active surveillance is gaining more and more supporters.
New studies and methods have brought more and more safety to this modality, in which there is no need for surgery, chemotherapy or radiotherapy.
Men with prostate cancer have benefited the most from this option. A study released at the American Congress of Urology in May showed that in the last seven years the number of patients with early tumors on active surveillance in the United States more than doubled — from 26.5% to 59.6%.
In these cases, surveillance means monitoring with tests, such as MRI, PSA (prostate specific antigen) and digital rectal exam, and periodic consultations with small, low-risk tumors and only treating them if there are signs of cancer progression.
Many cases of prostate cancer diagnosed using PSA are low-risk. This means that they are small, confined to the prostate, and not aggressive according to an international classification system (Gleason score).
According to urologist Roni Fernandes, vice president of the SBU (Brazilian Society of Urology), the option of active surveillance has also grown in Brazil, it is very well established in international studies and integrates the SBU guidelines.
“When you classify the patient very well before indicating any treatment, you are sure that he is at low risk, the chances of success are above 90%, equal to the traditional treatment, which is prostatectomy [retirada da próstata] and radiotherapy.
Among the criteria are the patient having PSA less than 10 ng/ml and only a small portion of the prostate affected. Genetic testing of the tumor, which can indicate whether it is high-risk or low-risk, has also been used.
Surgery can cause side effects such as urinary incontinence and erectile dysfunction. “When you suggest surveillance with security and the trade-off [a troca] is not having urinary incontinence and, mainly, not having erectile dysfunction, patients agree to do it”, says urologist Carlos Sacomani, editor-in-chief of the Bulletin of Urological Information, of the SBU magazine, regional of São Paulo.
For Sacomani, in Brazil, this option comes up against limitations when it comes to SUS patients. “In a country that has difficult access to primary care, early diagnosis of cancer, the question is whether we can catch the patient in the initial phase. Active surveillance presupposes adequate monitoring, the patient needs to be able to schedule an appointment, take the necessary tests. That’s the big challenge.”
Fernandes recalls that surveillance is only indicated if the patient undergoes consultations and exams every three months, digital rectal examination and magnetic resonance imaging every six months, and scheduled biopsies. “You have to turn surveillance into a religion. If you can’t afford it, it’s better to treat it.”
According to the urologist, active surveillance has also been adopted in kidney cancer, in situations where the tumor masses are smaller than 4 cm and the patients are elderly. “We follow up, do imaging tests. If the mass grows more than 0.5 cm a year, then we operate.”
In breast cancer, the active surveillance protocol has been extensively studied in cases of ductal carcinoma in situ, which are microcalcifications contained within the milk ducts of the breast. Studies indicate that less than 50% of these cases will become invasive tumors, that is, they can spread to other areas and require surgery and other therapies. The rest, in theory, could only be monitored. But there are still no sure ways to tell them apart.
Therefore, according to doctor Carolina Soliani, a member of the Brazilian Society of Mastology, there is no scientific support for not operating on young and healthy patients with this type of tumor. “In cases of very elderly patients, who have comorbidities and have a small in situ, we evaluate the benefit of surgery.”
According to mastologist José Luis Bevilacqua, in these cases, a “de-escalation” of treatments has been proposed, avoiding radiotherapy or chemotherapy or even more radical surgeries. “As physicians we must always consider the intensity or aggressiveness of treatments in the face of a patient’s comorbidities”, he says.
Today, there are three major studies worldwide following over 1,000 women with in situ breast cancer who are under active surveillance. The largest of them, with 932 patients, started recruitment in 2014 and ended in 2020. The group was divided between those who had surgery and those who are under the protocol of active surveillance. Patients will be followed for ten years and will have annual mammograms.
“We need these results to understand the behavior of the tumor and have confidence in the indication [da vigilância]. Today the question remains: ‘I wonder if, not operating, we will not be exposing this patient to have a [câncer] invader and progress the disease?”, says Carolina Soliani.
Massage therapist Rosangela Bittencourt, 63, was diagnosed with ductal breast cancer in situ almost 20 years ago and was referred for a bilateral mastectomy (breast removal). But after two years on the SUS waiting list, she gave up on the surgery and left for traditional Chinese medicine treatments.
“It was a difficult decision, but when I learned that after the mastectomy I still had to go through about eight procedures, I gave up and bet on other paths”, he says. She continues to monitor the microcalcifications with exams and medical consultations, but says they have decreased and are under control.
In the case of low-grade colorectal cancer, the Watch&Wait protocol (watch and wait), as it is known internationally, was developed by Brazilian physician Angelita Habr-Gama in the 1990s and manages to prevent the patient from undergoing major surgeries, which can result in infections, sexual and urinary dysfunction, in addition to the need for a colostomy [bolsa coletora de fezes].
The protocol showed that patients with this tumor respond well to treatment with radio and chemotherapy, without the need for surgery. But they need to make medical appointments for physical examination and perform laboratory and imaging tests.
Surgery is only performed if the tumor reappears, which happens in about 25% of cases, according to Rodrigo Oliva Perez, digestive system surgeon at Oswaldo Cruz Hospital (SP). He is the principal investigator of a multicenter study that will define the best treatment strategy for patients under the protocol.