Active surveillance patient selection and management

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Terry Herbert
Regular Member


Date Joined Sep 2010
Total Posts : 92
   Posted 10/22/2010 5:53 PM (GMT -6)   
Active surveillance for prostate cancer: patient selection and management L. Klotz, MD is a paper published in last month’s Current Oncology. I think it gives a very useful overview of the current issues surrounding Active Surveillance and should be read by any newly diagnosed man or anyone contemplating Active Surveillance as their ‘therapy’ of choice.

Some of the key points are:

1. A diagnosis of cancer often results, at least initially, in “cancer hysteria”—that is, a perfectly understandable reflexive fear of an aggressive life-threatening condition. For some cancers this fear is warranted, but for most men with favourable-risk prostate cancer, their condition is far removed from that of a rampaging, aggressive disease. Most men with favourable-risk prostate cancer are not destined to die of their disease, even in the absence of treatment. This view is echoed by luminaries such as Dr Christopher Logothetis who said many years ago

“One of the problems with prostate cancer is definition. They label it as a cancer, and they force us all to behave in a way that introduces us to a cascade of events that sends us to very morbid therapy. It's sort of like once that cancer label is put on there we are obligated to behave in a certain way, and its driven by physician beliefs and patient beliefs and frequently they don't have anything to do with reality.”

And Dr Jonathon Oppenheimer who said

“For the vast majority of men with a recent diagnosis of prostate cancer the most important question is not what treatment is needed, but whether any treatment at all is required. Active surveillance is the logical choice for most men (and the families that love them) to make.”

2. Some studies demonstrated that prostate cancer typically begins in the third or fourth decade of life yet the median age of death from prostate cancer is about 80 years. Dr Klotz says this implies a 50-year time course from inception to mortality and that most patients have a long window of curability, which is particularly true for patients with favourable-risk, low-volume disease. It also implies that young age at diagnosis should not preclude a surveillance approach. Of course there are tragic cases of young men dying from the disease, but as Dr Klotz says they generally have high-grade disease at the outset and represent a very small proportion of prostate cancer patients. According to the current SEER data less than 10% of cancer deaths (which account for about 3% of all male deaths) occur in men under the age of 54.

3. Although approximately 200 patients have been followed for between 10 and 15 years, it is acknowledged that most of the studies have immature data and it will be another 5-7 years before a median follow-up of fifteen years can be achieved. This will be a good deal longer than many of the published studies for other therapies which often have a median follow-up of five years or even less. In one study where 50% of the surveillance patients were eventually treated, absolutely no difference was observed in the mortality or the metastasis rate at a median follow up of about 8 years.

4. The paper sets out various criteria for the clinical follow-up for men who choose Active Surveillance and it is interesting to note the move away from the concept of frequent biopsy procedures once the basic diagnosis has been confirmed after 12 months. This will diminish what is sometimes referred to as a ‘side effect’ of Active Surveillance.

Choosing Active Surveillance is not without its risks, as are all options for the man diagnosed with prostate cancer. This paper does not deal with any potential loss of quality of life (QOL) that may come with the election of the AS option or make any comparison with QOL issues associated other therapy options.

The entire paper can be read here ACTIVE SURVEILLANCE FOR PROSTATE CANCER: PATIENT SELECTION AND MANAGEMENT
Diagnosed ‘96: Age 54: Stage T2b: PSA 7.2: Gleason 7: No treatment. Jun '07 PSA 42.0 - Bony Metastasis: Aug '07: Intermittent ADT: PSA 2.3 Aug '10

It is a tragedy of the world that no one knows what he doesn’t know, and the less a man knows, the more sure he is that he knows everything. Joyce Carey

tatt2man
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Date Joined Jan 2010
Total Posts : 2842
   Posted 10/22/2010 6:27 PM (GMT -6)   
The problem with prostate cancer is the difficulty in which to establish if it is a low risk - slow cancer or an aggressive high risk cancer.

If you take my basic numbers as per the standards of the Canadian Cancer Society (substitute ACS for those south of the border) - my basic stats would dictate AS ( see my stats below) ...
But due to the persistance of my family physician, I was strongly encouraged to see an Urologist who repeated the DRE and PSA - which lead to biopsy - which lead to surgery as my form of treatment...
If I had done the typical guy thing and shrugged off the initial tests as being "safe" and did not pursue it, who knows where my cancer and my body would be now....
Even with gleason 7 and stage3a cancer pathology, I am currently undetectable - and am doing my best to stay that way....

Cancer hysteria can go both ways - jumping in to cut it out and regretting the choice (devoid of research and support to get the best treatment for the individual - whether it be AS, RP or LRP or seed or HT or...) - or ignoring as so many men do...

I am content with my choice - I wish all who participate in this forum to be content in their research and their choice in their individual treatment.

BRONSON
Age: 55 -gay with spouse, Steve - live in Peteborough, Ontario, Canada
PSA: 10/06/2009 - 3.86
Biopsy: 10/16/2009- 6 of 12 cancerous samples, Gleason 7 (4+3)
Radical Prostatectomy: 11/18/2009
Pathology: pT3a- gleason 7 -extraprostatic extension -perineural invasion -prostate weight -34.1 gm
Post Surgery-PSA: April 8, 2010 - 0.05 -I am in the ZERO CLUB
Sept 23, 2010 -0.05 - again -hoorah !

Terry Herbert
Regular Member


Date Joined Sep 2010
Total Posts : 92
   Posted 10/22/2010 6:38 PM (GMT -6)   
I guess you didn't read the article Bronson, did you?

If you check the normal criteria, I don't think you would ever have been advised to pursue AS with your diagnosis.

This is what Kotz says in part:

Men under 60 years of age, for example, are better candidates if they fulfil the Epstein criteria for insignificant prostate cancer (no more than one third of all cores positive, no more than half of any one core involved, and a psa density below 0.15).

.... men under 70 with substantial Gleason 4 pattern (or any Gleason 4 pattern, some would argue 26) are not good candidates for surveillance. The evidence suggests that their likelihood of disease progression is about 3 times that of patients without a Gleason 4 pattern. Shared patient decision-making and “buy-in” is critical.

Your diagnosis would not fit the Epstein criteria since 50% of your biopsy samples were positive. Most would argue that with that much tumour volume with a T2b Gleason Score (4+3) AS would be too risky.
Diagnosed ‘96: Age 54: Stage T2b: PSA 7.2: Gleason 7: No treatment. Jun '07 PSA 42.0 - Bony Metastasis: Aug '07: Intermittent ADT: PSA 2.3 Aug '10

It is a tragedy of the world that no one knows what he doesn’t know, and the less a man knows, the more sure he is that he knows everything. Joyce Carey

tatt2man
Veteran Member


Date Joined Jan 2010
Total Posts : 2842
   Posted 10/22/2010 7:02 PM (GMT -6)   
I guess you didn't read my posting - if I stayed with the PSA of 3.86 and normal dre - as per the Canadian Cancer Society - all being within a safe range - I would have done nothing - but wait a year until another routine PSA and DRE...

- but the persistance of my doctor LEAD TO a second PSA and DRE which LEAD to a biopsy - which confirmed the fears of my family physician and urologist.

-and I did read the article -

Post Edited (tatt2man) : 10/22/2010 7:05:41 PM (GMT-6)


Terry Herbert
Regular Member


Date Joined Sep 2010
Total Posts : 92
   Posted 10/22/2010 7:46 PM (GMT -6)   
My apologies.

You didn't mention a negative DRE in your initial post or a clinical staging. I assumed, since the Urologist ordered a biopsy procedure after his DRE that the result must have been positive - otherwise why order the biopsy procedure? Unless of course there was a history of increasing PSA - again not mentioned.

I am sorry if I came to the incorrect conclusion but would be intersted to know why the Urologist orderd the biopsy?
Diagnosed ‘96: Age 54: Stage T2b: PSA 7.2: Gleason 7: No treatment. Jun '07 PSA 42.0 - Bony Metastasis: Aug '07: Intermittent ADT: PSA 2.3 Aug '10

It is a tragedy of the world that no one knows what he doesn’t know, and the less a man knows, the more sure he is that he knows everything. Joyce Carey

gift of breath
New Member


Date Joined Oct 2010
Total Posts : 15
   Posted 10/22/2010 8:05 PM (GMT -6)   
I was told by my Main Uro that 30% of all AS folks pass away from PC. What more should be said?



Diagnosed w/PC at age 62
6/1/09 PSA< 5.1
11/07/09 PSA< 5.6
DRE < abnormal
3/10/10 Bio <1 of 12 Pos
Gleason < 3+3, t1c
RP 6/15/10 Dallas VA
Post Op Gleason <4+3, t2c
Path clear all margins, tumor centralized in both lobes
both nerves saved
8/13 PSA< less than 0.01 (undetectable)
8/13 <1 pad
8/17 start Levitra (microscopic improvement)
9/9 > PSA less than 0.01 (undetectable)

Terry Herbert
Regular Member


Date Joined Sep 2010
Total Posts : 92
   Posted 10/22/2010 8:24 PM (GMT -6)   
Did you ask your Main Uro where he got that information? Did you read the study I posted and the references? I have never seen a study showing a disease specific mortality rate of 30% for AS men as they are defined currently - and I've read a lot of studies in the past 14 years.

We all live our lives the way we want to. I never trust an authority figure merely because they are an authority figure. I politely ask where I can get more information about what they have told me, if I think it is worth pursuing. That doesn't make my way of dealing with issues 'right' but it may result in my getting more information than a urologist, who may believe surgery is the answer to all problems and may not have bothered to read any of the multitude of studies on AS or other treatament modes, such as Proton Beam or Cryotherapy or even HIFU.
Diagnosed ‘96: Age 54: Stage T2b: PSA 7.2: Gleason 7: No treatment. Jun '07 PSA 42.0 - Bony Metastasis: Aug '07: Intermittent ADT: PSA 2.3 Aug '10

It is a tragedy of the world that no one knows what he doesn’t know, and the less a man knows, the more sure he is that he knows everything. Joyce Carey

gift of breath
New Member


Date Joined Oct 2010
Total Posts : 15
   Posted 10/22/2010 8:54 PM (GMT -6)   
That's right and I support your decision
Diagnosed w/PC at age 62
6/1/09 PSA< 5.1
11/07/09 PSA< 5.6
DRE < abnormal
3/10/10 Bio <1 of 12 Pos
Gleason < 3+3, t1c
RP 6/15/10 Dallas VA
Post Op Gleason <4+3, t2c
Path clear all margins, tumor centralized in both lobes
both nerves saved
8/13 PSA< less than 0.01 (undetectable)
8/13 <1 pad
8/17 start Levitra (microscopic improvement)
9/9 > PSA less than 0.01 (undetectable)

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 10/23/2010 6:28 AM (GMT -6)   
gift of breath said...
I was told by my Main Uro that 30% of all AS folks pass away from PC. What more should be said?

Decimal point error...closer to 3%, not 30%.  Not much higher than men who pursue aggressive treatment for PC.

gift of breath
New Member


Date Joined Oct 2010
Total Posts : 15
   Posted 10/23/2010 8:05 AM (GMT -6)   
Thank You for the correction. Please post link you used for your info. Thanks
Diagnosed w/PC at age 62
6/1/09 PSA< 5.1
11/07/09 PSA< 5.6
DRE < abnormal
3/10/10 Bio <1 of 12 Pos
Gleason < 3+3, t1c
RP 6/15/10 Dallas VA
Post Op Gleason <4+3, t2c
Path clear all margins, tumor centralized in both lobes
both nerves saved
8/13 PSA< less than 0.01 (undetectable)
8/13 <1 pad
8/17 start Levitra (microscopic improvement)
9/9 > PSA less than 0.01 (undetectable)

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 10/23/2010 9:01 AM (GMT -6)   
gift of breath said...
Thank You for the correction. Please post link you used for your info. Thanks
 
You can hardly open a AS study without finding this result.  Here's the abstract of one which was published this weekhttp://www.urotoday.com/index.php?option=com_content&task=view_ua&id=2232328
The results of recent published active surveillance protocols are promising; after a 10-year follow-up, Klotz, et al. found a 97% cancer specific survival in a cohort of 450 patients under surveillance
 
Please post the name of your "Main Uro" as a service to others here...so that we can all avoid him/her.  Thanks
 
 
 

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 10/23/2010 9:20 AM (GMT -6)   
added later...

By the way, I don't really think your "Main Uro" would be so stupid as to say that 30% of AS patients die of PC. My guess is that you might have misunderstood what he said because another of the commonly quoted AS statistics is that about 30% of AS patients have to move to an aggressive treatment (i.e., deferred treatment) because their case characteristics degrade. The 30% rate is commonly used here; 3% from death from PC.
 
Apologies for being blunt; Terry's response was much nicer.
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