Active Surveillance per Johns Hopkins

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Tudpock18
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Date Joined Sep 2008
Total Posts : 4241
   Posted 6/11/2009 6:12 AM (GMT -6)   
The following was posted in this morning's JH Health alerts.  On the Hopkins web site, it gives more specifc criteria that should be met before choosing this option.
 
Tudpock
 

The Case for Active Surveillance

When a prostate biopsy indicates cancer, you might think you have to choose a treatment quickly. But usually there's no need to rush. Prostate cancer typically is a slow-growing malignancy, and most of the time men have months to consider their options. In this Health alert, Johns Hopkins explains why active surveillance can be the right choice for some men.

The standard treatment options for prostate cancer include active surveillance, radical prostatectomy, radiation therapy, and hormone treatment. With active surveillance, a man opts to have no immediate treatment but undergoes close monitoring for cancer progression. Today this treatment approach is most often recommended for men with low-grade cancers that are believed to be small volume, especially older men whose cancers are unlikely to become life threatening during their remaining years of life.

The goal of active surveillance is to avoid unnecessary treatment in men whose cancer is unlikely to become life threatening over the next 10-15 years. Fewer than 10% of men who are candidates for surveillance take advantage of this approach.

Understandably, many men can't tolerate the anxiety and uncertainty of leaving a cancer growing -- even very slowly -- in their body. But with close monitoring, active surveillance can be a good choice for some. That's especially true for older men whose predicted life expectancy makes it unlikely that their cancer will progress in their remaining years of life.

The significant upside to active surveillance is that it allows a man to maintain an excellent quality of life without the side effects of radiation therapy or radical prostatectomy. But the approach requires close monitoring for signs of progression. This includes regular digital rectal exams (DREs), PSA tests, and a prostate biopsy each year or at some regular interval.

Not all prostate cancer specialists endorse surveillance. But research indicates that with careful monitoring, it can be a safe approach for many older men. Results of a 12-year study reported in the Journal of the American Medical Association showed only a 0.5% difference in the number of prostate cancer deaths between men treated with radiation therapy or radical prostatectomy and those whose cancers were managed with active surveillance.


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
2 of 16 cores cancerous
27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 6/1/09.  6 month PSA now at 1.4 and my docs are "delighted"!

Steve n Dallas
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Date Joined Mar 2008
Total Posts : 4840
   Posted 6/11/2009 9:14 AM (GMT -6)   
Today this treatment approach is most often recommended for men with low-grade cancers that are believed to be small volume, especially older men whose cancers are unlikely to become life threatening during their remaining years of life.
 
If I were 25 years older, I might have watched and waited...
 
Have a 70 year old friend who parents are 98 & 99...He didn't wait either cause he hopes to go another thirty years idea
Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
 
06/25/08 - Da Vinci robotic laparoscopy
Catheter in for five weeks.
Dry after 3 months.
 
10/03/08 - 1st Quarter PSA -> less then .01
01/16/09 - 2nd Quarter PSA -> less then .01
xx/xx/xx   - 3rd Quater skipped
05/14/09  - 4th Quarter PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.
 


goodlife
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Date Joined May 2009
Total Posts : 2691
   Posted 6/11/2009 9:52 AM (GMT -6)   
I am becoming concerned with more of this kind of talk, both by the AMA and these study groups. I do understand the nature of PCa, and the fact that it is slow growing, etc.

The problem is, they can't tell us what makes some tumors a Gleason 6, and some a Gleason 9. It does not appear to be time, but just a mutation factor, or some other reason that makes the same adenocarcinoma have multiple levels of aggresiveness.

The next shoe to drop will be insurance (be it private or government) will paying for PSA testing after a certain age. Currently there is a suggestion that 50 is a good cut-off. Many men on this forum would probably have full blown cancer and/or dead or dying had it not been for PSA testing in their 50's or 60's or 70's. It may become an economic issue rather than a lifesaving issue in the future.

Thank God I had doctors who believed that PSA testing was a vital part of my ongoing health care, that found my Gleason 9 before it got any worse.
Age 58
PSA 4.47
Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09
Nerves spared
0/23 lymph nodes involved
pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.
Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Thankful for early diagnosis, and U.S. healthcare
Living the Good Life, cancer free
6 week PSA undetectable. 


LV-TX
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Date Joined Jul 2008
Total Posts : 966
   Posted 6/11/2009 10:57 AM (GMT -6)   
Goodlife...you sure the cut-off was 50 and not 70? I thought that they wanted to limit testing after the age of 70...or at least that was the recommendation.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


engineer55
Regular Member


Date Joined May 2009
Total Posts : 121
   Posted 6/11/2009 12:48 PM (GMT -6)   
Is there anyone who thinks they will live less than 10 years, my dad is 82 and he did radiation. It is a good article in that it does mention age is a factor.

CPA
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Date Joined Feb 2008
Total Posts : 655
   Posted 6/11/2009 1:51 PM (GMT -6)   
Greetings, Tudpock.  One other note from an earlier posting - what about those of us who thought we had relatively slow growing gleason 6 cancer and then found out after surgery that it was actually a more agressive 4 + 3 = 7 cancer.  While I was relatively young at 55, I just couldn't imagine knowing I had cancer and not doing anything.  Watchful waiting can be the option for some, I just don't think I could do it. David
Age 55
Diagnosed Dec 2007 during annual routine physical
PSA doubled from previous year from 1.5 to 3.2
12 biopsies - 2 positive with 2 marginal
Gleason 3 + 3 = 6
RRP 4 Feb 08
Both nerves spared
Good pathology - no margins - all encapsulated - Gleason 4 + 3 = 7
Catheter out Feb 13 - wore pad for couple of days - pad free Feb 16
PSA every 90 days - ZERO's everytime!
Great wife and family who take very good care of me


goodlife
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Date Joined May 2009
Total Posts : 2691
   Posted 6/11/2009 2:21 PM (GMT -6)   
LV-TX,

I overgeneralized a little and did not footnote my statement because it was not my main point, my point being that setting an age for limiting testing is a dangerous precedent. In another thread talking about Canadian and Swedish health care cost control, this is one of the ways they can do it. By limiting the testing, or the number of doctors and health care facilities, they can control the costs to the governemnts.

The Canadian Task Force on Preventative Health does not recommend PSA testing for men over 50. The American Academy of Family Physicians makes statements something they should counsel men over 50 about the risks of PSA testing and DRE's, and potential follow-up with biopsies, etc. If the patient still wants to continue, then they can have the testing. Even the American Cancer Society is a little nebulous on recommending routine PSA testing over 50. They have some counseling verbage in their statements. The point is, if today it is 70, tomorrow it could 60, or 50, depending on factors not related to the welfare of the patient.

If I am 50 years old, have heart issues, or some other disease that I am not expected to survive more than 10 years, then PSA testing is not recommended. Medicine and the human body is that predictable. The 10 years is only some physicians estimate. This forum is full of men who have defied the odds and gone way beyond original expectations. I am thinking we ought to be recommending annual PSA for all men. How we treat it may vary, but the 1 in 36 that die from PCa could possibly have had a better shot at recovery. Maybe breast exams and pap smears are a parallel example in women. Recommended annually.
Age 58
PSA 4.47
Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09
Nerves spared
0/23 lymph nodes involved
pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.
Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Thankful for early diagnosis, and U.S. healthcare
Living the Good Life, cancer free
6 week PSA undetectable. 


LV-TX
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Date Joined Jul 2008
Total Posts : 966
   Posted 6/11/2009 2:55 PM (GMT -6)   
goodlife...thanks for the clarification. I am sure the debate over PSA testing will be around for sometime, or at least until there is a better marker that can be used to more accurately detect cancer. Personally I wish there was a better method than the tradition biopsy that is used today.

But the topic of active surveillance is a valid one in my opinion. An elderly person with complex medical issues, this to me would be a no brainer. I am not sure about younger people following this path, however there are several men that have and had reasonable success without treatment for many years. Problem is...at what point does the aggressiveness of the cancer change from a gleason 6 to 8 or above...and when you finally find out...are you now outside of the window for cure? Then what?
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4241
   Posted 6/11/2009 3:48 PM (GMT -6)   

Hi CPA:

You make an interesting point when you state that "Watchful waiting can be the option for some, I just don't think I could do it."  That brings up the whole phychological aspect of why different men with similar stats choose different treatments.  Some men just need to get the cancer out of their bodies, and surgery becomes the only option for those guys.  For me, that wasn't my psyche.  I just wanted to make an informed decision about cure, SE's, etc.  Actually, if I had been a bit older with different stats, I would have strongly considered active surveillance.

The logic can be the same for all of us, but the psychology of the situation differs greatly.

Tudpock


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
2 of 16 cores cancerous
27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 6/1/09.  6 month PSA now at 1.4 and my docs are "delighted"!

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 6/11/2009 3:49 PM (GMT -6)   
LV-TX

Agreed. I think we all do some active survelliance at some point in this treatment cycle. Obviously PSA every 3 or 6 months is very active survelliance.

I am just becoming concerned with the chatter about limiting access to certain helth care procedures to certain age groups, etc.

Once you start, it can be a very slippery slope for us "old folks" !
Age 58
PSA 4.47
Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09
Nerves spared
0/23 lymph nodes involved
pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.
Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Thankful for early diagnosis, and U.S. healthcare
Living the Good Life, cancer free
6 week PSA undetectable. 


John T
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Date Joined Nov 2008
Total Posts : 4250
   Posted 6/11/2009 4:49 PM (GMT -6)   
I think that active surveliance is a very good option no matter what the age. Sure there is a small risk, but side affects are 100% guarenteed in any treatment and in a large percentage of men they are permenant.
There are a number of ways to reduce the risks, a color doppler can set a base line and any changes can be easily seen. If PSA starts accellerating or if a biopsy shows an increse in gleason or # of cores positive treatment can begin.
I know that is a psycological factor for some guys, but some like myself wouldn't mind knowing PC is in my body, I just have to know that it is controled. I've probably had PC for 12 to 15 years without knowing it and never felt the affects.
Having 5 to 8 years of good life before having to live with the consequences of a treatment is a good option for many.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 6/11/2009 5:07 PM (GMT -6)   
Thank you John...as always your insight into this disease is very refreshing to read. Kuddos to you.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


Colin45
Regular Member


Date Joined Feb 2009
Total Posts : 216
   Posted 6/12/2009 12:33 AM (GMT -6)   
I think for active surveillance to be more of an option to a lot more men the testing needs to be a lot more precised. PSA cannot tell you if you have PC or not the PSA figure cannot say whether the PC is aggressive or not some people have low PSA with high Gleeson score, after a biopsy there is no guarantee that if PC is found that they can tell you the correct Gleeson score and how large it is unless you have a a lot of cores taken and what nobody seems to mention whether the position of the PC in the prostate can mean that the is more likely to spread outside of the prostate or not (is cancer near a wall more likely to spread that one in the centre). There is still worry the biopsies can also spread the cancer by tracking all this makes thinking about active surveillance very difficult to think about
 
 
Age 64 From UK now in Thailand 
Baby boy born 2/14/2009
 
First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08 
1/28/09 Biopsy carried out 12 core results were
findings
Both specimens show no adenocarcinoma
 
MRSI done on 5/8/09 No signs of any cancer
5/15/0924 Core biopsy results
Gleason'S Grade 3+2=5
Involving approx 30% of one out of 12 cores on each side
no perineural or angiolymphatic invation identified
One side PIN High Grade
Bone scan clear 
 


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 6/12/2009 8:01 AM (GMT -6)   
A wife chimes in here.

Active surveillance may be appropriate in some cases...and it is certainly up to the patient to decide what is right for him. However, since a biopsy cannot give a complete picture of what is going on in the prostate, it is possible for the cancer to be more aggressive or more invasive than shown on the biopsy. This was the case with my husband, who chose surgery. Fortunately for us, his was the right choice as the cancer had invaded the capsule (but not broken through it). The surgeon's words to us upon reading the surgical path report was "looks like we got to it just in time." With the capsule being such a thin membrane surrounding the prostate, who knows how long it would have been before the cancer broke through the capsule and started invading surrounding tissue. So far, 14 months post op, hubbie's PSA continues at 0.0.

Each man must decide for himself but, personally, my husband and I agreed (along with his doctor) that getting the cancer out was the best course of action for us.

Even though prostate cancer is "slow growing," I wouldn't want it growing in my body and giving it the chance to become a bigger issue than it needs to be.

Yes, I know I'm not the one who has to deal with ED and incontinence but watching someone you love deal with these issues is no bed of roses either. I wish all who are grappling with this decision good health.
Husband diagnosed in February 2008 (age 57). Cancer discovered during routine annual physical. Clinical Stage T1c, Gleason 7 (3+4), with 2 out of 10 cores testing positive. Perineural invasion identified on biopsy. DRE was negative.

Robotic surgery in March 2008. Pathological stage upgraded to T3a, Gleason still 7 (3+4). Miniscule invasion into prostate capsule but no cancer found outside capsule (surgical margins and seminal vesicles were clean).

1st PSA 3 weeks post op: 0.1; 2nd PSA 7 weeks post op: 0.0. PSA remains at 0.0, and will continue to be checked every 3 months for the first 2 years due to capsular penetration.

Took Enablex for urinary issues with good results. Currently not taking any medication for incontinence and continues to make progress in this area. Continues with 50 mg. of Viagara 2 to 3 times a week with good results there as well.


pa69
Regular Member


Date Joined Mar 2009
Total Posts : 260
   Posted 6/12/2009 8:28 AM (GMT -6)   
Hi all,

Just want to chime in on what I see as an arbitrary cutoff age of 70 for some of the health benefits. I'll be 70 in about a month. I consider myself to be in good health except for having to deal with prostate cancer. My parents lived to be a ripe old age (mother died at 99) and their parents lived long lives as well.

Because I'm 70 does that mean I no longer qualify for these benefits? I would like to think I could outlive my parents, meaning at least another 30 years.

Somehow depriving me of health benefits simply because of my age makes me think I am being discriminated against. I believe the patient's overall medical history and current medical condition should be the driving factor. Would the reduction in my health benefits reduce the cost of my insurance premium? Not likely. The fact that an age cutoff is even being considered makes me angry.

Sorry for the rant,
Bob
Age 69, First ever PSA 7.8 taken June 2008, Biopsy July 2008, 10 of 12 cores positive, Gleason 3+3=6
da Vinci surgery December 10, 2008, catheter removed December 29 2008
St. Lukes Hospital, Bethlehem, Pa.
Dr. Frank Tamarkin

Prostate weight 73.0 grams, Gleason 3+3=6, stage pT3a
Tumor locations: right anterior apex, right posterior apex to mid
left anterior mid to base, left posterior apex to mid
extensive perineural invasion in right anterior apex, right and left posterior apex to mid
seminal vesicles negative

First post PSA < .1 Jan 16 2009
Second post PSA < .1 Apr 17 2009


engineer55
Regular Member


Date Joined May 2009
Total Posts : 121
   Posted 6/12/2009 10:23 AM (GMT -6)   
In my opinion many surgeries and treatements should be avoided for later year patients, if it does not improve their quality of life why do it. It is just disturbing that for someone reason PC is more often singled out. It is a deadly condition. I talked to my surgeon about this and he was somehat upset, he basically said since early detection they have dramtically improved survival rates, and now there is a community who want to throw it all away.

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 6/12/2009 4:27 PM (GMT -6)   
Bob (pa69) The 70 was related to testing of PSA...with the thought that if they were to get PCa after that age, most likely the will die with the disease and not from the disease. I don't think it had anything to do with all other medical care or treatments. So for example yourself, if you haven't got prostate cancer by the age of 70, then there would be no reason to test the PSA unless there was some symptom like a positive DRE or some other symptom that might warrant testing.

Just wanted to clarify the meaning of the proposed 70 cut-off.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 6/12/2009 7:20 PM (GMT -6)   

PCa is the twilight zone because too much is unknown, undefinitive, and even unproven.

Issues exist with pathologists and then therefore uro-docs and others to know which type of PCa do you have, they have identified atleast  18 variants and they do not all respond the same to hormone therapies or treatments....thus another parameter of different results on patients. Alot of people could have a form of PCa that was not identified properly or even defined, thus how does anyone know if you have indolent or *****cat versions vs. the tigers (aggressive) e.g.  'small cell prostate cancer' a variant you hope you do not have to deal with, it is worse than others types and prognosis is worse for patients in general. Or even among patients with the same gleason scores and same type of PCa, another parameter is thrown in which type of plodity do you have (3 exist) it is extra testings that can be done by expert pathologists....aneuploid is the better one to have, diploid is next best, tetraploid or such is the worst and the dna strands are of little or no structure  (chaos)...so this would not respond to treatments the same as the aneuploid. Then mention our own biological make-ups and health conditions, blood types etc., the variations become hugely complex.

One size never fits all in PCa, nothing is totally definitive at any level. Active surveilence is not insane but is best when used along with reasonable testings to see how viable is it and for some patients it is very viable. 

The more you find about PCa, the more unprecise you realize the whole thing is and this is why the controversies are so diverse and on going.


 

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