Hopkins newest data on their AS program.

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John T
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   Posted 4/13/2011 11:30 AM (GMT -6)   

zufus
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   Posted 4/13/2011 3:15 PM (GMT -6)   
Hey John, have not read this link yet. Are you aware of Dr. Duke Bahn's new 10 point assessment for A.S., includes color doppler rating thing and alot more. See it on line at www.paactusa.org     (then click on Newsletter, newest issues just out, top selected date) starts like on page 2 or 3.  Now I am not saying it is easy to do or anything, but just to look at the info concept.

John T
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   Posted 4/13/2011 4:50 PM (GMT -6)   
Zufus,
I saw it. It is much stricter than most of the other programs out there and much more detailed.
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Tony Crispino
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   Posted 4/13/2011 5:04 PM (GMT -6)   
It's also very conservative.

Good article. i still think that we need data on the young guys but this protocol is not far deviated from the NCCN guidelines for AS.

I can subscribe to this protocol for many.

Tony
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
Da Vinci Surgery ~ 2/16/2007
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.
Undetectable PSA.

Blog: www.caringbridge.org/visit/tonycrispino

Tony Crispino
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   Posted 4/13/2011 5:07 PM (GMT -6)   
Attached is the article that zufus is referring to:

www.paactusa.org/cc%20vol%2027-1%20%20March%202011.pdf

Tony

Casey59
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   Posted 4/13/2011 5:17 PM (GMT -6)   
TC-LasVegas said...
 i still think that we need data on the young guys...
 
 
The data says that young guys are more likely to eventually progress to a deferred treatment...no surprise.  [It actually has nothing whatsoever to do with their age...it has to do with the number of years on AS.]  Complementary data says that there is no degradation in outcome by deferring treatment.  In fact, initiating treatment 5- or 10-years from now may very well have better outcomes than treatments initiated today because of the rate of continuous improvement in the treatments...both the current set of aggressive treatments, or the further development of other emerging treatments.
 
 

Tony Crispino
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   Posted 4/13/2011 5:23 PM (GMT -6)   
Yea I saw it but that isn't the data I was referring to. i was hoping to eventually see some details. There was a reason that the NCCN recommendation for AS excluded men whom had a 10+ year life expectancy for low risk cases and 20+ year life expectancy for very low risk. That is not addressed in the Bahn article. I asked Tim Wilson about it and he said simply that there is not enough 20 and 30 years data on PCa and these men will typically live that long and we don't know what repercussions there might be.

I would reckon that eventually we will have that data and see recommendations like Bahn's more commonly. Unless of course the long term data is not favorable.

Tony

Fairwind
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   Posted 4/13/2011 6:20 PM (GMT -6)   
769 men enrolled over a period of 16 years.. 48 men a year qualified for Hopkins AS program..

I wonder how many men IN TOTAL Hopkins treats for prostate cancer every year...Something way more than 48 I bet..How many radical prostatectomies were performed at Johns-Hopkins during this same time period??

Tudpock18
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   Posted 4/13/2011 6:38 PM (GMT -6)   
JT and Bob, thanks for sharing. 
 
Casey said, "In fact, initiating treatment 5- or 10-years from now may very well have better outcomes than treatments initiated today because of the rate of continuous improvement in the treatments...both the current set of aggressive treatments, or the further development of other emerging treatments."  I think this is a very important point that is often an afterthought in our AS discussions.  Suppose TFT becomes more widespreard as a mainstream treatment or HIFU is approved in the USA?  More options with potentially better QOL might await a man who is eligible to defer treatment....excellent point, Casey!
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

John T
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   Posted 4/13/2011 6:40 PM (GMT -6)   
Fairwind,
In another study I posted a few weeks ago it was determined that only 9% of those eligible for AS took it up. The real eye opener was that the vast majority of men that met the criteria were never even offered that option. I have no problem with anyone deciding to forgo AS and get treated, but I think it is a crime that the majority of men who were eligible were never given information on it. Those of us that advocate AS are sometimes accused of thinking that any low risk patient that didn't choose AS is stupid. This cannot be futher from the truth, a patient can't make an intelligent decisions if he is not provided information on all the options. The information given to new patient on the AS option is sorely lacking as the surveys show. I'm not suggesting that Hopkins did this, but it is a universal problem.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

ralfinaz
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   Posted 4/13/2011 7:00 PM (GMT -6)   
The problem John T is that if Carter or Klotz can't get a decent number of candidates going for AS, how can we expect that plain uros will do it. As more time and confidence is gained for the protocol, it will happen for the benefit of men. Like many things with prostate cancer, it takes time...
Phoenix, Arizona
Surviving prostate cancer since 1992. RP; Orchiectomy;
GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall. Last PSA September, 2010: <0.1 ng/ml
Laughter is the best medicine!
www.pcainaz.org/phpBB304

Fairwind
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   Posted 4/13/2011 7:14 PM (GMT -6)   
I agree 100% John..The docs don't make much money on AS (they will soon learn how to make money on it) so they tend to push expensive, invasive, treatments..But the heat is on concerning over-treatment and that's a good thing.

But these doctors are making decisions that in many cases are life or death, so we can expect them to favor more aggressive treatment..a pure CYA reaction on their part..Too bad we all can't be evaluated and treated in the big cancer research centers..

Cheers, F>airwind.. cool

Casey59
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   Posted 4/14/2011 10:11 AM (GMT -6)   
TC-LasVegas said...
There was a reason that the NCCN recommendation for AS excluded men whom had a 10+ year life expectancy for low risk cases and 20+ year life expectancy for very low risk.
 
Tony, just a few words of clarification.  Not sure from your words here (above) if you understood this point or not, but there is an important, but subtle distinction between the way I read your post and what the NCCN did/said...
 
I recently listened to a live online presentation by Dr James Mohler where he reviewed the 2010 Update of the NCCN Prostate Cancer Treatment Guidelines...which, as you know, included the definitions of "low-risk" and "very-low-risk" PC which you refer to above.  Dr Mohler is Chair of the NCCN PC Treatment Guidelines Panel, and his clinical practice focuses on prostate cancer and robotic-assisted surgery.  In the presentation, Dr Mohler took time to make this subtle point very clear...I posted this passage (below) a few days ago in the thread titled "If the term 'cancer' weren't part of the diagnosis...", and I'll just copy/paste from there (but this time adding underlines for emphasis):
The Guidelines goes on to say that AS should be the only option offered by doctors to low-risk patients will <10 yrs life expectancy, and very-low-risk patients with <20 years life expectancy, AND should be offered as an option (although not the only option) to men in those risk categories at any age.
 
AS is not excluded from the NCCN recommendation for the age groups you described in your post; quite the contrary.  It's just that it is no longer the ONLY recommendation that the Guideline provides for guys with longer life expectancy.
 
I hope that this provides additional clarity.
 
best wishes...

Purgatory
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Date Joined Oct 2008
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   Posted 4/14/2011 10:25 AM (GMT -6)   
Although not based on a very large pool of patients, in my opinion, the data provided some pretty good numbers in defense of AS.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

medved
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   Posted 4/14/2011 10:48 AM (GMT -6)   
I wonder if it is really true that docs make less money on AS than on treatment (eg, surgery). AS typically involves mutliple office visits, repeated psa tests, annual biopsies, maybe imaging, and then some non-trivial percentage of the patients getting treatment anyway. So maybe AS is not so unprofitable?

Tony Crispino
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   Posted 4/14/2011 3:16 PM (GMT -6)   
Casey
Thank you reciting what I know, but, your clarification does not address why there is this demarcation in the guidelines based on life expectancy..

Perhaps my wording should be simplified. Using the NCCN guidelines ~ and Tim Wilson whom I saw speak on it is on the NCCN Committee and presented them clearly (City of Hope is in the consortium), the rules are not the same for the younger or longer life expectancies and it's for a reason. Otherwise the guidelines would include no options and the they would remain rigid for all ages and life expectancies with low or very low risk patients. But that is not the case and they excluded younger men from the same rigid position and it's for a reason.

Why is it only to be suggested as an option by longer age/life expectancy criteria? It's likely because it matters that we lack sufficient data for the NCCN to put their stamp on it. I know many men in their younger 40's could delay therapy...I suspect that the reason that the younger men being excluded as a "requirement" to recommend AS is partially because even if a man in his 70's does AS and it takes a bad turn he can still easily outlive the disease through hormonal therapies and such. This might not be the same if a younger man whose disease takes an abnormal turn. I know these risks are not well studied and the guidelines stop short here. Offering the patient that falls into the "optional" category AS as an option would require an thorough explanation of why it isn't just suggested the same way as for those with shorter life expectancies.

There are obviously "cons" and they need to be explained.

{edited-fixed cell phone typing errors and etiquette}

Tony

Post Edited (TC-LasVegas) : 4/14/2011 10:22:31 PM (GMT-6)


Casey59
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   Posted 4/15/2011 10:16 AM (GMT -6)   
TC-LasVegas said...
Thank you reciting what I know....
 

Sorrry…I guess your wording was not clear, but more broadly it appeared to me that not everyone visiting this site understands this point (and in fact, some specifically misunderstand it):  Specifically, that the NCCN position is NOT a recommendation against AS for all ages; rather, that it IS an OPTION for all ages, but it is the ONLY RECOMMENDATION for men with less than 10 years life expectancy.

There are lots of guys pointing at the decline in PC mortality the last decade or so as a victory of PSA screening, but not all realize that the death rate went up dramatically in the beginning of the PSA-era.  Radical prostatectomy surgery became common in the over-75 age group in the late-80’s/early 90’s.  It is these surgical elderly that were dying in large numbers of post-operative clots in their coronaries and lungs – iatrogenic deaths that were ascribed to prostate cancer.  The decline in mortality since the mid-90’s is in no small measure a returning to the pre-PSA era levels as the aggressive/major surgeries of men in this age group began declining (and the PSA-era resulted in younger-and-younger men diagnosed with smaller-and-smaller amounts of PC).

The age-stratified PC mortality is dominated by the very elderly, and the overall declines in mortality is also primarily driven by the steep decline in deaths in the highest age groups.  The NCCN has made a very strong statement that not only is AS a very viable option of any age, but it should be the only recommendation that doctors give to patient with <10 yrs L.E. (for “low risk” PC), or <20 yrs L.E. (for “very low risk” PC).

Regarding the “option” to patients with longer L.E. (life expectancy), there is not a complete absence of risk in undertaking AS, nor is there a complete absence of risk in undertaking any of the aggressive treatments; but it is clear that there are many who have undergone aggressive treatments which resulted in more harm than good.  The “option” for treatment is a recognition that is no path is the universal “best” choice…there is no one-size fits all solution.  Treat the patient, not the cancer.


Casey59
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   Posted 4/15/2011 10:39 AM (GMT -6)   
Further to my previous posting, interesting comment made by Dr Willet Whitmore about 20-years ago (before robotics, before proton therapy, before HIFU, etc) relating to the high number of radical prostatectomies performed on the elderly (with high mortality outcomes):
"The current state of prostate cancer may not be good medicine but it sure is good business."
 
 
 

Galileo
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   Posted 4/15/2011 11:33 AM (GMT -6)   
John T., thanks for posting that.
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) Jan-Mar 2007
PSA 9/2007 and thereafter <0.1
pcabefore50.blogspot.com

Tony Crispino
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   Posted 4/15/2011 11:41 AM (GMT -6)   
#1 20 years ago there was little alternative to treating localized prostate cancer than surgery. There are plenty of options available today that are far less invasive.

#2 "...not only is AS a very viable option of any age, but it should be the only recommendation that doctors give to patient with <10 yrs L.E. (for “low risk” PC), or <20 yrs L.E. (for “very low risk” PC)."

I hope doctors apply more common sense and explanation than what is written here. There is certainly cases that should be AS but there is no way to determine indolent versus aggressive disease. According to this article MOST will exit the AS program as I have stated before. For some it was just a personal decision and for others the plan simply failed and diverse conditions existed. It is my belief that the above quoted line is simply an inadequate explanation of what the intent of the demarcation means from the NCCN.

See the link John posted again...

(Does anyone notice that more than half in this study eventually vacated the AS decision by year 10. I think I was pummeled here in the past when I suggested this would be the case for most that do AS)

Anyone can do AS. That I don't argue. And SOME outside the parameters of the group that would receive a "blanket" recommendation should absolutely NOT do it. I agree with you final comment that each case should be evaluated versus taking these guidelines and applying them rigidly. Not all men with 25% of 3 cores positive, a PSA of 4.5 and Gleason 3+3=6 should sit on their diagnosis, especially for example if they young such as a 38 year old.

To suggest it is acceptable because the NCCN leaves open that door ~ and it is borderline ludicrous to apply the NCCN statement in recommending AS to such cases...The parameters are separate for a yet still unexplained reason on this thread. As my comments are in Mikes post in the link above, a doctor should need to explain the WHY AS for longer LE isn't in the blanket recommendation as opposed to just saying "ah shucks you can still do it"...

We also know that men with more diverse risk factors can do AS if they have co-morbitity that will likely be their demise. At least they will get a better explanation than what we have defined today for those that are "optional".

Tony

Post Edited (TC-LasVegas) : 4/15/2011 10:55:53 AM (GMT-6)


Purgatory
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   Posted 4/15/2011 12:07 PM (GMT -6)   
Tony, I did note how many people dropped off AS, was wondering if anyone else picked up on that point.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, 2/11 1.24, 4/11 3.81
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10

Tony Crispino
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   Posted 4/15/2011 12:24 PM (GMT -6)   
Purg,
Only 9% dropped out by personal decision. The rest saw something that changed their approach.

To all the dissenters of my comments to require an in depth explanation as to why the blanket statement of the NCCN is exceptioned I will make two statements and I am interested in their response:

Statement #1 ALL men with less than 20 years life expectancy that have Gleason 3+3=6 and parameters outlined in the NCCN guidelines should forego therapy and just watch the disease.

Statement #2 ALL men with Gleason 3+3=6 and parameters outlined by the NCCN should go on active surveillance regardless of life expectancy...

I am interested in the responses...

Tony

Post Edited (TC-LasVegas) : 4/15/2011 11:27:27 AM (GMT-6)


Casey59
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   Posted 4/15/2011 12:32 PM (GMT -6)   
These statements appear ignorant (not saying that you are ignorant, but that these statements ignore) of the premise of closely monitoring AS patients for a change in status, and moving to treatment (essentially without consequence) if they do progress. Patients are closely monitored.

Patients who move off of AS to treatment are considered case successes! It worked! The roughly 25%, or closer to 50% by 10 years, who sought deferred treatment via active surveillance were successfully deferred. Note earlier discussion on understand what a "success" is: http://www.healingwell.com/community/default.aspx?f=35&m=1932436

Tony Crispino
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Total Posts : 8128
   Posted 4/15/2011 12:47 PM (GMT -6)   
I wouldn't say either statement so I know I am not being ignorant. I am just trying to figure out if this was where people stand on this. The recommendation of the NCCN is in line with the first statement. I made no mention of the follow up but rather the automatic inclusion for AS under the guidelines. I fully understand they will be "active" in watching the disease I didn't say "forget about it and ignore the disease."

And BTW how do you know it worked? Is it because the study shows that at a median of 2.7 years there was no recognizable harm...?

Ugh...for my part I hate short sighted retrospective studies. 768 men is hardly a cohort that will represent this class of patient should the guidelines be followed rigidly. I would love to see the data at the ten and twenty years median mark since that's whom these stats truly affect.

I would also like JHU to start breaking these types of studies down by age groups.

Tony
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
Da Vinci Surgery ~ 2/16/2007
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.
Undetectable PSA.

Blog: www.caringbridge.org/visit/tonycrispino

Purgatory
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Date Joined Oct 2008
Total Posts : 25393
   Posted 4/15/2011 12:59 PM (GMT -6)   
tony,

that was my original comment, the fact that it was only 768 men. i don't fully agree with the first statement, and i definitely don't agree with the 2nd, as there are still other factors and circumstances involved.

david
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, 2/11 1.24, 4/11 3.81
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10
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