A majority of urologists and radiation oncologists are still not recommending active monitoring (“active surveillance”) as a first-line method for the management of patients with low-risk prostate cancer.
This information comes from a media release issued by the Mayo Clinic last Friday and referencing data presented by a Mayo Clinic-based research team at the annual meeting of the North Central Section of the American Urological Association just completed in Chicago.
We have not seen any of the details from this presentation by Dr. Simon Kim and his colleagues, so all we can tell readers is what appears in the media release, as follows:
- The research team surveyed 643 urologists and radiation oncologists.
- Only 21 percent of physicians studied recommended active surveillance for low-risk disease.
- 47 percent of physicians studied recommended surgery for men with low-risk disease
- 32 percent of physicians studied recommended radiation therapy for low-risk disease.
- Physician recommendations generally aligned with their area of expertise.
- Urologists generally recommended surgery.
- Radiation oncologists generally recommended radiation therapy.
We should note that we are missing a lot of information about this study, and so the results listed above should be interpreted with caution. For example:
- We have no idea what percentage of the 643 physicians surveyed actually responded to the survey (or whether 643 was the number of physicians who responded out of a much larger number to whom the survey was sent).
- We therefore do not know whether the 21 percent of physicians who said they did recommend active surveillance was 21/100 responders or 135/643 responders.
- We do not know what questions were actually asked of the participants, and how the questions were asked could profoundly impact individual responses.
It is not exactly surprising to learn that the majority of urologists and radiation oncologists still need to be convinced that active surveillance is a perfectly reasonable way to manage men with low-risk prostate cancer (and most particularly older men with limited life expectancies). Most urologists and radiation oncologists would probably say that we still only have data from case series on which to base decision making about this strategy (conveniently ignoring the fact that the same is true for treatment of low-risk patients with radiation therapy or surgery).
However, if we assume that the questions posed to the target audience for this survey were well framed, and that the number of actual responders was 643, then it is still distressing to see such a high proportion of the urology and radiation oncology communities unwilling to acknowledge the fact that the risks associated with immediate first-line treatment may well be outweighing the benefits — most particularly in older men with limited life expectancies.
“Our results may explain in part the relatively low use of active surveillance for low-risk prostate cancer in the United States,” Dr. Kim, a urologic oncologist at the Mayo Clinic, is quoted as saying in the media release.
Filed under: Diagnosis, Management, Risk, Treatment Tagged: | active, monitoring, radiation, surgery, surveillance, therapy
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According to the nomogram on the Memorial Sloan-Kettering Cancer Center’s web site, the 15-year cancer-specific survival rate for 53-year-old patients with Gleason 6, PSA = 5, T1c disease who undergo radical prostatectomy would not fall from 99% to 98% until they progressed to Gleason 8 (the Gleason score being the most important factor).
It seems to me that there is a lot of opportunity to wait to see if the disease is progressive with very little, if any, increase in 15-year risk of death from cancer. Even the 15-year risk of death from cancer at Gleason 10, PSA = 5, T1c, age = 53 is still 2%. If you’re willing to tolerate a 1% increase in 15-year risk of death from cancer, you can let it progress a long way (which usually takes a long time).
Dear Chris:
I think we need to be clear that the data projected by the Kattan nomogram are based on the presumption that the patient does indeed have immediate treatment and doesn’t practice any form of deferral of treatment. I do not believe it would be wise for any 53-year-old patient with Gleason 4 + 3 = 7, or Gleason 8 to 10, to be practicing active monitoring. The situation might be different for an 80-year-old, but not for a young man.
All that the nomogram on the MSKCC web site can tell us at this time is that if you have early stage, localized disease, with a relatively low volume of tumor (regardless of Gleason score), then radical surgery (when conducted by a skilled prostate cancer surgeon) can give you a high probability of recurrence-free survival at 10 years and prostate cancer-specific survival at 15 years. What we need is a new nomogram that allows Dr. Kattan or others to project risk for progressive disease, metastatic disease, and prostate cancer-specific survival for men who have been on active surveillance or active surveillance followed by definitive treatment for 10 or 15 years, stratified by age, stage, PSA level, Gleason score, and number of positive biopsy cores at the time of starting active monitoring. As yet, the data are not available to construct such a nomogram (based on one set of data) or to validate its accuracy (against a second set of independent data).
“I think we need to be clear that the data projected by the Kattan nomogram are based on the presumption that the patient does indeed have immediate treatment”
That indeed is what I presumed. I was comparing immediate treatment of the low-risk patients that the article was talking about with treatment at a more advanced stage. I was using the nomogram as a means of confirming that active monitoring is an appropriate strategy for those patients. Was there something wrong with my argument?
Dear Chris:
The Kattan nomogram is based on a large set of patients who were treated at a point in time when very few men were considered to be candidates for active surveillance. As a consequence, they never got confirmatory biopsies (or any other form of test such as an MRI) prior to surgery to see if they really did meet low-risk criteria.
As a consequence, men classified as having Gleason 3 + 3 = 6 disease (or lower) when the Kattan nomograms were created almost certainly had a higher probability for upgrading (and perhaps upstaging too) than a man with low-risk disease entering a well-structured active surveillance protocol today.
My point is only that we cannot be sure your analysis is actually based on a comparison of apples to apples, and therefore needs to be considered with a significant degree of caution. At least a subset of the men who were given surgery and included in the database that comprised the Kattan nomogram would almost certainly not be recommended for surgery today (by the same surgeon whose patients formed the basis of the Kattan nomogram).
“As a consequence, men classified as having Gleason 3 + 3 = 6 disease (or lower) when the Kattan nomograms were created almost certainly had a higher probability for upgrading (and perhaps upstaging too)”
So you’re saying that men classified as having Gleason 3 + 3 = 6 disease today can expect a better prognosis than men classified as having Gleason 3 + 3 = 6 disease when the Kattan nomograms were created. Does that not mean that the nomogram confirms that active monitoring is an appropriate strategy for those patients classified as having Gleason 3 + 3 = 6 disease today? (along with the other factors, of course). And doesn’t it also imply that the nomogram is actually pessimistic for men classified as having Gleason 3 + 3 = 6 disease today?
Dear Chris:
(1) No. I am not saying that men classified as Gleason 6 today can have a better prognosis. That is one possible interpretation of what I wrote. All that I am saying is that you cannot compare apples and oranges in this way and necessarily expect reliable conclusions.
(2) The nomogram has always confirmed the idea that active monitoring is an appropriate strategy for some men with low-risk disease (i.e., not just a Gleason score of 6 but also a PSA < 10 ng/ml and a relatively low tumor volume). Most particularly that is the case for men who the nomogram indicates as having a high probability of indolent disease.
(3) You cannot reasonably draw the conclusion that the nomogram is pessimistic for men classified with Gleason 6 today. Is it a possible hypothesis? Yes, it is, but it needs to be tested. The Kattan nomograms were never designed to predict the effectiveness of active surveillance. There are all sorts of technical reasons why they should be used with great caution with respect to the interpretations that you are implying.
“No. I am not saying that men classified as Gleason 6 today can have a better prognosis.”
Then I have no idea what you mean when you say “As a consequence, men classified as having Gleason 3 + 3 = 6 disease (or lower) when the Kattan nomograms were created almost certainly had a higher probability for upgrading (and perhaps upstaging too)”, especially when you use the words “almost certainly”.
“not just a Gleason score of 6 but also a PSA < 10 ng/ml and a relatively low tumor volume"
That's what I said originally, "PSA = 5, T1c"
"You cannot reasonably draw the conclusion that the nomogram is pessimistic for men classified with Gleason 6 today."
Then what does "men classified as having Gleason 3 + 3 = 6 disease (or lower) when the Kattan nomograms were created almost certainly had a higher probability for upgrading (and perhaps upstaging too)” mean?
Dear Chris:
This appears to be a circular argument because I am saying something very simple (which is that you cannot compare apples and oranges) and you are trying to make a comparison based on what I see as apples and oranges. I don’t think we are going to get any resolution of this type of discussion in an online forum like this.
OK, I just don’t know what “men classified as having Gleason 3 + 3 = 6 disease (or lower) when the Kattan nomograms were created almost certainly had a higher probability for upgrading (and perhaps upstaging too)” is supposed to mean.
Dear Chris:
It means exactly what it says. At the time the diagnostic data were being collected that were used to create and validate the Kattan pre-treatment nomogram, (a) most men got 6- or 8-core biopsies rather than 12-core biopsies (and so were arguably being under-sampled); (b) many men were still being classified as having Gleason scores lower than 6 and went on to have radical prostatectomies (which means that in today’s world they would be put on an active surveillance protocol by the surgeon who was then giving them an RP).
Thus, compared to a man being diagnosed today with Gleason 6 disease, the chances are high that men being diagnosed at that time (in the early to mid 1990s) and entered into the database used to create the Kattan nomogram, the nomogram is biased by success in treating men who didn’t actually need treatment and failures in men who were diagnosed with disease that was more favorable than it actually was.
Remember that this conversation started by you trying to extrapolate from the Kattan nomogram with respect to decisions about the potential of active surveillance. I just don’t think you can use the Kattan nomogram to do that … at all. It wasn’t designed for that purpose and we have no idea how many of the men included in the databases used to initially create and later update the nomogram were really potential candidates for active surveillance at all (or according to what criteria).