We recommend to our readers a recent article in Medscape Oncology entitled “What’s impeding active surveillance in prostate cancer?” The article is based on a review by Cooperberg et al. in a recent issue of the Journal of Clinical Oncology. However, the full text of that review article is not easily accessible for most patients and advocates. By contrast, the article on the Medscape web site is available to anyone who registers with Medscape (and there is no cost).
The key point made by Cooperberg et al. and repeated by Mulcahy in the Medscape article is that it is going to take time and education (of physicians and of patients) to transform the generations long belief that first line treatment for any forms of solid tumor is simply to “take it out.” Surgeons are taught this from the earliest days in medical school. Patients learn this from their older friends and relatives. Society teaches this through its general articles about the management of cancer.
As we must have said a dozen times before, just this year alone, the really critical issues in understanding the value of active surveillance and applying it correctly are: (a) decisions about who is an appropriate candidate (“defining eligibility”) and (b) being able to accurately identify those men on active surveillance who are at clinically significant risk for progression and who therefore need invasive treatment (“identifying progression”).
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk Tagged: | acceptance, active surveillance, education
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The article in Medscape Oncology points out that active surveillance is best suited to older patients, in particular if they suffer from co-morbidity. An additional class of patients that should consider active surveillance are younger patients who may safely defer the occurrence of side effects (in particular ED) until surgery or other first-line of treatment is necessary.
I’ve been on active surveillance now for 3 years and along with some good CAM (complementary alternative medicine) from my naturopathic doctor have seen my PSA drop about 25% and prostate volume shrink by nearly 30%. No growth, spread, or change in the cancer either. Just about time for another PSA test, which I’ll get in the next few weeks.
I am a bit concerned about the repeat biopsies (now one a year) and wonder if they might increase the risk of spreading, or activating the cancer in some way. I’m 59 years old and in otherwise good health/shape.
I agree, there needs to more and better education for patients and families of those diagnosed with prostate cancer about active surveillance. I participate in several on-line prostate cancer support groups. The suggestion of active surveillance is almost seen as insulting by many members of the group. From their replies to questions about active surveillance it clear they have been told to “cut it out.” Anything less won’t do.
Before I’ll say we have over-diagnosed or over-treated I will say active surveillance has been seriously under-used. But for some reason I cannot lose that voice in my head that says “be careful what you wish for”.
It says that AS is labor intensive and poorly reimbursed. If health care reform improved the reimbursement, would it make a difference in physician attitudes? I am not sure that is a big issue. I think uncertainty and fear are bigger impediments. Maybe when more doctors have real clinical experience it will make them more comfortable?
Relative to RP, AS is more labor intensive in the long-term, less well-reibursed in the short-term, but actually rather well reimbursed in the long-term. The real problem is that, to a surgeon, it is not surgery, so it is not what “a real surgeon” was trained to do.
How is it more labor intensive? It requires repeated PSA tests and annual biopsies. PSA tests are also part of the protocol for any other first-line of treatment follow up, so that can’t be that. The only other “labor intensive” activities are the annual biopsies. I can hardly think these would be considered to be “labor intensive.”
The two problems are indeed surgeon and patient attitudes. The surgeon is indeed trained to treat and not to wait and many patients cannot live with the thought that they have cancer in their body and that they don’t do anything to treat it.
I’m in agreeance (as the Aussies term agreement) with Phil here. As Dr Christopher Logothetis said in an address to Us TOO back in 1993 (can that really be almost 20 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.”
So … no real change then from that position.
But in any of these discussions the one issue for which only one side is presented is the threat (real or imaginary) of legal action. Now before anyone explains to an alien like me how litigatious the US system is — I know. I was in the insurance business for all of my career and I know how much litigation there is; how many media-making awards are overturned on appeal; how much spin the insurers put on the problem to raise premiums; and how much money is made.
So, with that in mind, I read in this study:
‘ “Once you know there is a cancer, you have to be very careful,” Dr. Thrasher noted. If the patient opts for active surveillance but then is noncompliant with regular follow-up tests, and a metastatic prostate cancer is discovered after a few years, then there is danger — especially in the litigious environment of the United States — of a claim of medical negligence, because there might have been a window of opportunity for curative treatment that was missed, he explained.
‘Dr. Cooperberg and colleagues also cite “medicolegal” risks as a retardant to the uptake of active surveillance.’
And I think “How big is the risk?” and I think “How big is the risk of being sued when the man finds that a post-operative pathology report shows no sign of malignant growth? Isn’t that a pretty big risk too, given the numbers of such cases said to exist?”
Seems to me Dr Lam has it right when he says:
‘… with a patient who is carefully oriented to active surveillance, “we are not very concerned about lawsuits.” ‘
Additionally/alternatively, perhaps urological “surgeons” will ultimately turn out to not be the most appropriate first-line specialist for the management of low-risk/low-grade prostate cancer.
As healthy, lucky folks in our 40s, our adventures to date on Planet Prostate have proven an object lesson on the literal truth of the old saw, “When one’s only tool is a hammer, everything looks like a nail.”
Perhaps we need prostate cancer active “surveillists,” a sub-specialty committed to minimizing the risk of inaccurately diagnosing an indolent prostate cancer as prostate cancer that requires treatment, managing cases of low-risk, low-grade prostate cancer to minimize the risk of too early and excessive treatment, and providing pre- and post-medical management and educational support to minimize quality-of-life-destroying side effects for men whose prostate cancer does progress to the point of productively and rationally requiring invasive, radical intervention.
I understand that there are practicing urologists who are trying to establish active surveillance as a standard method of treatment and who genuinely understand the moral quandary of over-treatment, both treating too soon and too much. However, today, evolved urologists must evolve on their own — some do; some do not.
A “surveillist” specialty as a part of medical training would normalize/mainstream the protocol as both a form of practice and an area of research, and perhaps provide the missing perspective in research design that gets us to that Voilà! moment of reclassifying indolent “prostate cancer” as an abnormality that is unethical to treat with radical, quality-of-life-altering procedures and gives some better tools for distinguishing between low- and high-risk prostate cancers.