Active Surveillance

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John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 11/17/2009 2:03 PM (GMT -6)   
Here are some interesting facts about Active Surveilllance that were published by Klotz, a long time researcher in Active Survelience. He gathered these while reviewing the 18 studies on AS as well as data from his own research study.  J. ClinOncol 23:8165
 
Gleason 6, Stage T1C- T2A, PSA less than 10 are favorable stats for AS
 
- A PSA doubling time less than 2 years is associated with more agressive PC and a high likeyhood of locally advanced PC.
-Determination of agressive vs non agressive PC can be determined in 2 years with 8-10 psa data points and 2 sets of biopsies.
-1.7% of those with favorable low risk stats will die within 10 years DISPITE any aggressive local treatment.
-70% will show no sign of progression.
-20% will be treated because of PSA progression.
-10% will be treated because of Gleason Grade progresson
- Decision to treat made when PSA doubling time is less than 3 years or Gleason grade increases.
In other studies I have read indicate that the cure rate for delayed treatment is exactly the same as if the treatment was done immediately.
My take on this and other studies done on AS is that the "window of cure" is fairly long and if you just happen to be one of the 1%-2% with low stats, but agresssive PC the window was never open to you anyway. Given a 70% chance of non progression and a similar cure rate to immediate treatment if progression does occur AS is a no brainer for those with low risk stats.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4154
   Posted 11/17/2009 2:55 PM (GMT -6)   

John:

Good post.  It's clear (at least to me) that AS is a suitable alternative for those who qualify.  When I was reviewing my options a year ago I was hoping to qualify for AS but did not because of my G7.  But I did discuss it with the folks at Johns Hopkins who have a specific AS program that is managed by their head of adult urology.  Shown below are the Hopkins criteria and some follow up results.

Tudpock

 

Eligible men should meet the following criteria:

  • older age -usually men in their 60’s or those with other health problems
  • cancer can not be felt on digital rectal examination (referred to as stage T1c)
  • PSA appropriate for prostate size meaning that the PSA density (PSA divided by ultrasound determined prostate volume) is 0.1 or less
  • combined Gleason grade or score is 6 or less and no more than 2 biopsy cores contain cancer and
  • cores containing cancer should not have more than 50 percent involvement with cancer

...about 30 percent of men with follow-up have had adverse findings on a repeat prostate biopsy one year or more after the initial prostate biopsy diagnosed the cancer. At this point, treatment was recommended because of the biopsy findings showing more cancer (more than 2 cores with cancer, and/or more than 50% involvement of any core with cancer, and/or high grade disease). Of the men who have undergone surgery to treat their prostate cancer at the time the follow-up biopsy showed adverse findings, the proportion with curable disease appears to be similar to those men who would have qualified for the program but chose to undergo surgery immediately instead of expectant management. Thus, it would appear that when men are carefully selected for expectant management, the window of opportunity for cure is unlikely to close with monitoring.


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 9/1/09.  6 month PSA  1.4 and my docs are "delighted"!

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/17/2009 3:06 PM (GMT -6)   
Great Post, actually some pretty consitent info there. There is a narrow criteria for safe AS, and it should be encouraged where applicable. As you said John, for those with agressive variants, there isn't a window anyhow. Good info here.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys cath #8 33 days, 11/2- SP Cath #9 in place


Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 11/17/2009 3:09 PM (GMT -6)   
I began to suspect a few months after my dx that this disease could be over treated. Since then the trend is showing me more and more to be correct. Now it's becoming clearer that many cancers early on fall into this category. Like I've said, in the future people will look back at this time and be aghast. How many guys have had their quality of lives negatively impacted for little to no reason? The answer a few years from now will be very sobering. Remember at one time people thought lobotomies were the correct option to take too.

Tud I suspect soon the Hopkins criteria will be even less restrictive.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/17/2009 3:22 PM (GMT -6)   
If we do look back one day at this period as the "age of overtreatment", and I am not totally convinced in all cases, then at least I hope the motivation for doing so was primarily for the purpose of saving lives from cancer deaths, and not from doctors and hospitals from making more money then they already do.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys cath #8 33 days, 11/2- SP Cath #9 in place


Herophilus
Veteran Member


Date Joined Sep 2009
Total Posts : 662
   Posted 11/17/2009 3:26 PM (GMT -6)   
Very interesting! I'm going to try to get the full text. Thanks for he post.
I feel that AS should be a option in the treatment of PCa However my problem with it all, is that my biopsy as reviewed by a very qualified group of pathologist was a G-6. This was with 10 of 12 cores being positive and up to 75% of on of the cores. So they had lot's of tissue. Then my post-op pathology is a hard 7 that being 4+3=7. “Gleason 7 found in all 4 quadrants” My concern is that until a reliable (repeatable) biopsy platform is developed that consistently has the specificity as related to post op pathology I have some difficulty with the recommendation of AS. PSA velocity, and doubling rate... all important. I would have loved to avoid my surgery but, it just wasn’t to be. It’s just so darn problematic, this disease is!
Age 51, PSA 08/31/2009= 6.8, DRE Neg.
Biopsy 9/24/09 =10 of 12 positive. Gleason 6. 75% of one core.
da Vinci at Wash U, Barnes on 11/02/09
Pathology Changed Gleason to 4 + 3 = 7. Gleason 7 present in all 4 quadrants
All(4)periprostatic Lymph Nodes Negative, All(10)pelvic Lymph Nodes negative
Seminal Vesicles tumor free. No prostate extension


Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 11/17/2009 3:27 PM (GMT -6)   
Purgatory said...
If we do look back one day at this period as the "age of overtreatment", and I am not totally convinced in all cases, then at least I hope the motivation for doing so was primarily for the purpose of saving lives from cancer deaths, and not from doctors and hospitals from making more money then they already do.



I suspect it will be both. You can't deny that PSA has been a financial windfall for many.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/17/2009 3:44 PM (GMT -6)   
Ziggy,

Not a doubt in the world about that part, the money part. With the cost of biopsies, the push for immediate surgeries or RT, sure there are hundreds and hundreds, if not thousands of urologists/rad clinics/hospitals that have made untold billions off of our fears of cancer and of the plight of having it.

As bad as that sounds, still glad to be living somewhere, where tests and treatments and doctors and hospitals abound to treat those in need. Not sure I would want the alternative. There is no bliss in ignorance about cancer in my opinion, early detection and treatments when needed still save a lot of lives.

Proably no easy answer or solution, just needs to be a balancing point somewhere in the process.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys cath #8 33 days, 11/2- SP Cath #9 in place


Rolerbe
Regular Member


Date Joined Dec 2008
Total Posts : 235
   Posted 11/17/2009 3:55 PM (GMT -6)   
Good post, and I agree that we will look back on this as an era of overtreatment. Hell, I might be one of them. I don't regret my own choices, made after careful review of the best information available at the time, but hope for better for future generations.

I do take real issue, however, with all the recent press advocating ignorance (no testing, etc.). Get the facts and treat as appropriate, with AS considered as a bona fide treatment. I suspect most here would agree. The recent articles have done society an injustice. Just sticking one's healthcare rationing head in the sand and trying to pawn it off as 'protecting' the public is disingenuous and no solution.
51 YO
PSA at Dx: 8.2
DaVinci RALP: 10/31/08 -- Great MD in New Haven, CT
Negative margins, no extra-capsular involvement
One nerve spared
PSA at 0 for just over a year now.
 
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/17/2009 4:16 PM (GMT -6)   
Rolerbe,

I agree with you, what is this new drive in the media about backing off testing for prostate cancer first, and now recently, the thread is still below, breast cancer. It seems bound and dertimined to undermine a whole generation of getting the message out to get tested early.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys cath #8 33 days, 11/2- SP Cath #9 in place


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 11/17/2009 6:52 PM (GMT -6)   
Herophilous,

I hear what you're saying, but nothing in the PC world is without risk; you just have to go with the best odds and hope for the best. With your stats, 10 positive cores, even with a G6, it was obvious that you had something serious going on and not eligable for AS. Most non agressive cancers would have only 1 or 2 cores positive, with a low core %. These take a long time to grow into a G7 if they ever do. The volume of your PC alone, along with your young age indicated that it was growing quite fast. Also your fairly low PSA doesn't correlate with a high volume G6 tumor (psa decreases as Gleason Grade increases), a sharp doctor would have suspected that you had a higher Gleason than your biopsy indicated. It's key to get a doctor with a lot of experience in AS as he can spot things a normal doctor wouldn't.
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 DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


engineer55
Regular Member


Date Joined May 2009
Total Posts : 121
   Posted 11/17/2009 7:20 PM (GMT -6)   
What turned me off from AS were the biopsies, could not pin down the dr. but he wanted #2 at 16 months. I decided if that was the system might as well go all the way, I found the biopsies less than pleasant and they seemed to just hit my deductible so I paid the whole deal. If they said come back in 2 years it would be more appealing. Clearly PC is a big killer, seems we should celebrate the many options available, some cancers have few.
Dx'ed 5/08 one core 2%  out of 12  3+3 gleason
DREs all negative
PSA was in the 3-4 range then jumped to 7
I have the enlarged prostate, on the order of 100cc.  After taking Avodart for 3 months  my
PSA was cut in half.
I did Active S for a year but concluded that I didn't want a life
of biopsies and Uro meetings.
DaVinci on 6/24/09  UCI Med Center  Dr Ahlering, long surgery based on size and location
Final was 5% one side all clear, but had a huge 90 grm prostate
Now we work on pee control, ok at night but sitting is a big problem.

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