The problem with active surveillance.

[pjoshea13]

New Swedish study below. [1]

Over-detection of PCa has led to overtreatment, & ultimately, to the U.S. Preventive Services Task Force (USPSTF) recommendation against PSA–based screening for prostate cancer.

At one point, Dr. Myers suggested "Don't call it (Gleason 3+3) cancer!"

That's all very well, but 25-30% of GS:3+3 progress.

With active surveillance [AS] the 70-75% of men who will never see progression are asked to undergo annual biopsies. The remainder, who might benefit from immediate treatment, are asked to wait until the cancer has advanced enough to be detected via biopsy. There are tests that might help men find out which group they are in, such as the 4Kscore. No more biopsies for the one & timely treatment for the other.

What is the cost of AS to those destined to progress?

"In total, 52 men (39%) experienced at least one feature of unfavorable pathology at radical prostatectomy."

-Patrick

ncbi.nlm.nih.gov/pubmed/297...

J Urol. 2018 May 3. pii: S0022-5347(18)43081-9. doi: 10.1016/j.juro.2018.04.078. [Epub ahead of print]

Long-term outcomes after deferred radical prostatectomy in men initially managed by active surveillance.

Godtman RA1, Schafferer M2, Pihl CG3, Stranne J2, Hugosson J2.

Author information

1

Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden. Electronic address: [e-mail].

2

Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden.

3

Department of Pathology, Institute of Biomedicine, Sahlgrenska Academy at University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden.

Abstract

PURPOSE:

To determine the long-term outcomes after deferred radical prostatectomy.

MATERIAL AND METHODS:

The study population consisted of all men with screening-detected prostate cancer who underwent deferred radical prostatectomy (n=132; 1 Jan 1995-31 Dec 2014) after active surveillance in the Göteborg Randomized, Population-based Prostate Cancer Screening Trial. The last date of follow-up was 15 May 2017. Follow-up during active surveillance was performed with prostate-specific antigen (PSA)-tests every 3-6 months and repeat biopsies every 2-4 years. Triggers for radical prostatectomy were disease progression (PSA, grade, and/or stage) or patient request. The outcomes included adverse pathology at radical prostatectomy (Gleason score>3+4, extra-prostatic extension, positive margins, seminal vesicle invasion, and/or N+), whether or not the index tumor at radical prostatectomy was identified at biopsy, and PSA relapse-free survival. The Kaplan-Meier analysis was used.

RESULTS:

The median time from diagnosis to surgery was 1.9 years (IQR 1.2-4.2 years) and the median follow-up time after surgery was 10.9 years (IQR 7.5-14.5 years). In total, 52 men (39%) experienced at least one feature of unfavorable pathology at radical prostatectomy. The 10-year PSA relapse-free survival was 79.5%. The index tumor was not identified in the diagnostic biopsy in 29% of the men (38/132) or at the last repeat biopsy that preceded radical prostatectomy in 21% (22/105).

CONCLUSIONS:

A large proportion of men had unfavorable pathology at deferred radical prostatectomy and the index tumor was frequently not identified. There is a clear need for better risk classification and protocols for determining disease progression during active surveillance.

Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

KEYWORDS:

prostatic neoplasms; treatment

PMID: 29730198 DOI: 10.1016/j.juro.2018.04.078

[FCoffey]

Annual biopsies are a bad idea. Take a strawberry, and jam 12 or more largish needles through it. Take them out and do it again. And again, and again, and again. That's what your prostate looks like after 5 biopsies. Those holes fill with scar tissue, and the inflammation and rapid growth required to heal from the injuries promote cancer growth.

We don't have as many studies as women with breast cancer, but they have research showing the women who get needle biopsies are much more likely to have distant lymph node involvement compared to women who get MRIs or lumpectomies. Biopsies definitely spread the cancer.

I insist on MRIs. They are very good these days, and can even give a pretty good idea of the grade - if you can find a radiologist who is willing to talk directly to you. It's officially verbotten to admit that MRIs might do something that takes boat payments away from urologists, so grades measured by radiology are rarely included in written reports. Biopsies are a billion dollar a year business. That's a lot of boats.

The first rule of any test is not to do it if it won't change your treatment options. Once PCa has been confirmed, MRIs can tell if there is growth, extracapsular extension, pelvic lymph node involvement. Whole body MRIs can detect distant bony metastases as least as well as most PET/CT scans - with no radiation dose. That's all you need to make an informed decision about changes to treatment plans.

[rocket09 in reply to FCoffey]

That is me as well. No biopsies as they cannot reach into the front of the prostate where some of it is for me. MRI did find it and going for my second one soon to monitor.

[FCoffey in reply to rocket09]

Great point - and another reason to demand MRIs while refusing biopsies. MRIs image the entire prostate as well as the surrounding tissues and anatomy. Biopsy can't do that.

[j-o-h-n in reply to FCoffey]

Unfortunately for us most urologist's boats are only equipped with one oar..hense they only go around in circles.

Good Luck and Good Health.

j-o-h-n Thursday 05/10/2018 5:33 PM EDT

[ritchiek in reply to j-o-h-n]

At Guy’s Hospital, London, they do template biopsies. Quick GA , about 24 template biopsies, plus extra biopsies of areas of high suspicion from a previous MRI prostate.

No pain , & plenty of tissue to analyse from all parts of the prostate.

[ARIES29]

Nobody mentioned the pain of a biopsie on the prostate.I was told to look at the wall & hang on to a bar while ? up my rear end. Sure it confirmed it & the tissue went away for further tests but it will not happen to this little black duck again!!