How Safe is Active Surveillance?

[pjoshea13]

New study [1] - a bit off-topic for this group.

As most in the U.S. will know, the USPSTF (U.S. Preventive Services Task Force) turned against PCa screening because of over-detection & over-treatment.

Perhaps as a reaction to over-treatment, we now have more men opting for active surveillance [AS].

Dr. Myers, speaking about Gleason score [GS] 3+3 on his vlog, said "Don't call it cancer." However, 25-30% of men on AS will progress, & some will perhaps miss the window for curative treatment.

The decision to sign-up for AS is largely based on biopsy results. The new study looked at GS upgrades in men after radical prostatectomy.

"One hundred and thirty-six patients who were eligible for AS at the time of RP were included in this study."

Almost half of the men were upgraded. A quarter of those were upstaged to pT3a.

7.4% of the patients were upgraded to Gleason 4 + 3, and 3.7% of the patients were upgraded to Gleason 4 + 4.

IMO, the decision to opt for AS should be made using GS plus blood/urine tests. And perhaps the decision to be on AS might one day not involve a biopsy at all.

-Patrick

[1] ncbi.nlm.nih.gov/pubmed/312...

Prostate. 2019 Jul 3. doi: 10.1002/pros.23873. [Epub ahead of print]

The pathological upgrading after radical prostatectomy in low-risk prostate cancer patients who are eligible for active surveillance: How safe is it to depend on bioptic pathology?

Verep S1, Erdem S1, Ozluk Y2, Kilicaslan I2, Sanli O1, Ozcan F1.

Author information

Abstract

BACKGROUND:

Active surveillance (AS) is one of the treatment alternatives in low-risk prostate cancer (PCa). The pathological upgrading after radical prostatectomy (RP) were investigated in patients who were eligible for AS in the present study.

METHODS:

Between August 2006 and July 2017, 627 patients underwent RP in our institution. One hundred and thirty-six patients who were eligible for AS at the time of RP were included in this study. The previously defined AS criteria Gleason 3 + 3=6 adenocarcinoma at maximum two biopsy cores, prostate-specific antigen (PSA) < 10 ng/mL and clinical T stage ≤ 2a were used in the study. The demographics, clinical, and histopathological outcomes were retrospectively compared between two groups, which were divided in accordance with the upgrading status at final pathology as Group 1 (n = 67, upgrading) and Group 2 (n = 69, nonupgrading).

RESULTS:

Gleason upgrading (GU) was found in 67 (49.3%) patients, and 17 patients (12.5%) were upstaged to pT3a. The upgrading to Gleason 3 + 4 was reported in 38.7% of patients, however, 7.4%, and 3.7% of the patients were upgraded to Gleason 4 + 3, and Gleason 4 + 4, respectively. The 10.3% of the patients had extraprostatic involvement, and the rate (19.4% vs 1.4%, P = .002) was significantly higher in Group 1. PSA density (P = .001), tumor size (P < .001), tumor percentage (P < .001), apical involvement (P = .013), and perineural invasion (P < .001) in RP specimen were higher in Group 1. Multivariate analysis showed that perineural invasion (OR = 4.26; 95%CI: 1.76-10.33; P = .001) and pathologic T stage (OR = 5.45; 95%CI: 1.08-27.4; P = .04) were independently associated with GU.

CONCLUSIONS:

Since 12.5% of the patients upstaged to pT3a disease, and there is a possible risk of Gleason 4 pattern, upgrading of the tumor should carefully be kept in mind before offering AS to low-risk patients with PCa.

© 2019 Wiley Periodicals, Inc.

KEYWORDS:

active surveillance; gleason upgrading; prostate cancer; radical prostatectomy

PMID: 31269285 DOI: 10.1002/pros.23873

[Fairwind]

With AS, being absolutely sure you are a genuine G-6 is imperative. As you pointed out, biopsies frequently miss hidden spots of high-grade cancer which can lead to serious trouble down the line. Having a saturation biopsy performed by a skilled technician might give you enough assurance to risk AS treatment...

[Schwah in reply to Fairwind]

And I found that three different pathologists can grade a tumor with three different numbers. It happened to me. No kidding.

[AnnieAppleseed in reply to Schwah]

Early on in my own cancer journey I came across a study of 11 pathologists reviewing approx 7 specimens. No agreement.

[2b-lucky]

When trying to calculate the odds of AS backfiring, we’re using old information to hit a moving target. But I don't know of a better option.

The study ran from 2006 to 2017. During that time, how many patients were diagnosed using the current state-of-the-art techniques? Like targeted biopsies, annual MRIs, and genetic tests?

Assuming that many of those 136 patients were diagnosed using a standard 12-core TRUS biopsy, (which misses so much cancer, as we know) it’s surprising to me that only 11% of the men were upgraded to Gleason 4+3 or higher. And even more surprising that half were not upgraded at all.

When I chose AS in 2015, I knew there were risks with AS, and there still are. MRI and targeted biopsies can sometimes miss high-grade tumors. But I feel the risks have declined considerably, as more accurate diagnostic tools have come along, and continue to be refined. Does that make sense? Or am I just kidding myself with wishful thinking?

[AlanMeyer in reply to 2b-lucky]

It makes sense to me.

Unfortunately, I don't think we can always count on our urologists or our general practitioners either to perform the more unusual tests, to solicit or even advise 2nd opinions on the biopsy, or to ensure that we get regular PSA or other tests. As with all important health care decisions, I think we have to educate ourselves about what to do. If we do that then I think there is still risk in AS, but there's also risk in treatment and we can make informed judgments about which risk to accept.

Alan

[2b-lucky in reply to AlanMeyer]

I agree. We each have to educate ourselves, and that's why websites like this are such a godsend. Our most knowledgeable colleagues, like Patrick, provide an invaluable service.

[Sxrxrnr1 in reply to 2b-lucky]

Statistics(that’s what PCa is all about) suggest 10 year survival rates for g6 cancers are near 100 percent, treated or not. The undiscussed secret,,,as older men get most prostate cancers,,,many/most have unknown or known competing morbidities. Many of which will lead to an early demise,,,often years before a PCa recurrence does occur

Treatment is no guarantee of cure as overall recurrence rates,,,this for all classes,,,approach 40 or more percent.

Therapy side effects,,,many lifelong debilitating with great suffering,,,are assured for the overwhelming majority undergoing local intrusive treatment.

10 years from now, who wants to bet that we will not have vastly superior options for successful treatment or perhaps likel even a cure, or certainly treated as a chronic disease with little of existing side effects

On top of this, the knowledge that as a 65 year old man,,,there existed almost a 50 percent chance that a competing morbidity ,,likely not even yet visible,,,could do me in before 80 anyhow.

Weighing all the odds,,,for me, I would do exactly what I elected to do 14 years ago when diagnosed with a G9,,,which was to do nothing but submit to regular PSA testing an annual scans.

I recommend that everyone considering active surveillance or watchful waiting,,,,research the very well known studies of treatment verses no treatment.

They are the US Government PIVOT STUDY and the SWEDISH STUYY. The SWEDISH STUDY commenced in 1993 and is still being monitored of the few remaining survivors,,,currently showing that treatment added perhaps 2 years of additional life expectancy verses non treatment,,,,however ONLY for those who were under 65 years of age at diagnoses. At 15 years outcomes were almost a tie with an advantage to treatment,,,but again for those under 65 at diagnosis.

Odds are that if you were to query your Physician(s) on these studies they would know nothing of them or plead ignorance.

For me alternative of an almost 100 percent assurance of a horribly diminished QOL balancing all these facts was a no brainer.

Additionally if I had treated,,,it is certain that I would not have fortunately discovered 7 years ago a lung cancer at an early stage that I was cured of with a simple surgery and zero chemo. And likely would have succumbed more than 5 years ago. This only because of PCa driven annual CT and MRI scans

I do not recommend route this for anyone..I am reporting what I chose. I am dealing with the fallout now as late 2017 with my PSA at a reading of 70,,,subsequent scans show multiple Mets.

I have no regrets and would do the same again,,,likely even more so because of the apparent possibility that after thousands of years of almost zero success in treating this disease,,,and all other cancers,,,,we are finally beginning to get a grasp. For 12 plus years my QOL was zero impacted or compromised in any way.

[AlanMeyer in reply to Sxrxrnr1]

You made a courageous choice. It's possible that it would have worked out better if you had chosen treatment, but it's also possible that it would have worked out the same plus living with the side effects of treatment for many years.

I wish you the best for the future.

Alan

[Sxrxrnr1 in reply to AlanMeyer]

Thank you Alan. Once I made the decision as to my direction, I never had a doubt that it was correct for me.

I did not blindly make it in a vacuum. I consulted with Kaiser where first diagnosed, Dr. Rossi at Loma Linda in Proton Radiation, Charles Ryan along with a number of fellow Physicians at UCSF, Dr. King RO at Stanford. I had CT’s and inter-rectal Gadolinium and Pyruvate trials, color Doppler’s, etc...and researched all the books and internet sources I could find,,,not once relying on the National Enquirer(as once accused) for insights, but instead NEJM, Lancet, BMJ, Sloan Kettering, Johns Hopkins, Mayo, Cleveland Clinic,,,the list is long.

At the time way back then, I remember reading that fully 90 to 95 percent of men diagnosed with PCa elected immediate therapies of RP, various RT options or ADT. Very few chose none of the above. Of course this has changed considerably in the past 5 to 8 years. Likely to a much improved QOL for 100’s of thousands of men,,,and in my somewhat informed opinion with very little increase in PCa specific death rates

I fully anticipated this current crises may if unlucky may/would eventually come. Statistically odds were still heavily in my favor. I willingly took the bet, having no regrets,,,assuming I likely would be exactly where we are now,,,but having gained at minimum 12 years of a great QOL with no suffering from the all too commonplace side effects that otherwise I would have missed.

I recall once reading of a quote from a compatriot of Patrick Walsh of Johns Hopkins,,,”300 men over the age of 65, must be treated to save a single life at 10 years”. I liked what he had to say,,,I will have to refresh myself on his name,,,was a bit unusual,,,last I recall he was in charge of Hopkin’s AS program which he started some 8 or 9 years ago.

All things considered and analyzed, suggested that for me with a G9 diagnosis that the likelihood of years of a severely diminished QOL submitting to a full monte of medical treatments would not change the ultimate outcome in any meaningful measure. Perhaps, just perhaps add a year or 2 to a miserable QOL,,,nothing meaningful.

14 years ago there was little or no so called active surveillance,,was then called watchful waiting,,,or crazy folks whistling past the graveyard.

Dr. Ryan after consultation with him 2 or 3 times,,,told me that if I did not follow Dr. Green’s surgery recommendations, I would be a dead man in 2 Years.

Dr. Hartzstart(sp) of UCSF who was running MRSI trials 12 to 14 years ago,,,when asked by me as we were reviewing one of my trials how long did she think I might live if I did nothing. She responded, likely at least 10 years, that was encouraging. As a MO, she is excellent. Understand she now is with Kaiser. .

She was in her own way preaching to the choir,,,she was well aware what I was doing.

Edit. H. Ballantine Carter of Johns Hopkins was the Urologist that made the quote suggesting that 300 men must be treated to save a single life at 10 years.

[AnnieAppleseed]

To me this is simple, I would NEVER 'wait' around for things to get worse. I would and did (for breast cancer), immediately change my diet to almost 100% organic. I started on dietary supplements and a physical activity program. I worked to reduce stress, learned about detox (juiced and did coffee enemas). And importantly had acupuncture.

[j-o-h-n]

My wife has me on active surveillance ever since she found a pair of panties in the glove compartment.

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 07/05/2019 5:46 PM DST

[j-o-h-n]

I actually told her they were mine.... but she's so smart because they're not my size and they were the crotch-less...type...

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 07/05/2019 6:13 PM DST

[DarkEnergy]

Hi Patrick,

"However, 25-30% of men on AS will progress, & some will perhaps miss the window for curative treatment."

This is me, 5 years ago at age 53, PSA 6, GS 6, I opt for AS. Then about 3 years of "Semi Active Surveillance", I've lapsed with PSA testing.

Then, at age 58, BANG!

All of a sudden, incontinence, burning sensation when urinating and blood in semen. Next day, got an emergency visit with the Urologist, the following day got a call from the office, the nurse said: "The doctor needs to talk with you ASAP..".

PSA 1000+, the journey began, the pelvic MRI looked like a Supernova...

Regards,

DarkEnergy, formerly known as NYMets