Interpretation, speculation, and the politics of prostate cancer

On Tuesday this week, an article appeared on the widely-read Politico web site entitled “The politics of prostate cancer.” It was based on the recent surgical treatment of U.S. Senator Ron Wyden. And it included some rather odd statements.

Let us be very clear up front … We have absolutely no idea what the exact nature of Senator Wyden’s cancer was. We don’t know his PSA, his clinical stage, his Gleason score, or pretty much anything else about his disease. All we really know is Senator Wyden’s age (he was 61 on May 3 this year) and what he said in a statement on November 16:

“After my annual physical in late November, I was diagnosed with early stage prostate cancer.  After reviewing all the options with multiple physicians, I decided to take a proactive approach and have surgery, which will be performed December 20 at Johns Hopkins Hospital by Dr. Alan Partin.”

What we can assume from this statement and what little else we know is that Senator Wyden was a reasonable candidate for the usual range of possible treatments for localized disease (surgery included) and that he may have been a candidate for active surveillance. However, given his age at 61 years, with a reasonable life expectancy of another 20+ years, it is very likely that he may not have met NCCN criteria for active surveillance and that he may also not have met criteria laid down by Johns Hopkins for their active surveillance protocol, which are relatively strict.

Despite this, the Politico article suggests that Senator Wyden “chose surgery for prostate cancer over ‘active surveillance.’ ” It also suggests that in doing so, Senator Wyden has put “himself — through no fault of his own — in the middle of a debate about diagnosis, treatment and bending the cost curve.”

The “New” Prostate Cancer InfoLink thinks that both of these suggestions are at best misleading.

In the first place, we have no idea whether anyone recommended active surveillance to the senator, so active surveillance may never have been an appropriate choice for him. If he had Gleason 3 + 4 = 7 disease, then he wasn’t a good candidate for active surveillance to begin with.

In the second place, the idea that active surveillance is necessarily less costly than other forms of management for prostate cancer is not true. That depends on the frequency and degree of monitoring, for how long such monitoring is needed, and whether the patient subsequently needs or decides to have definitive first-line treatment. Active surveillance probably is less costly than definitive treatment for an 80-year-old man who dies of a cardiovascular condition within 3 years of his diagnosis of prostate cancer. However, it probably isn’t less costly than definitive treatment for a 60-year-old man who is monitored regularly and carefully but without definitive treatment for the next 15+ years.

There are all sorts of issues that need to get resolved about the most appropriate methods of early diagnosis and management of men with localized prostate cancer. Among these are:

  • How can we differentiate between truly indolent and truly clinically significant disease that needs treatment?
  • Who should be advised that watchful waiting (which is not the same as active surveillance) is highly appropriate as a management strategy?
  • Who should be advised that active surveillance is highly appropriate as a management strategy?
  • Who should be advised that early invasive treatment of some type is most appropriate?
  • Which of the various invasive treatment options currently available is “the best” and “for whom”?
  • Can we improve the post-treatment quality of life of the men who do need to have invasive treatment?
  • Can and should we offer supportive therapy for men on active surveillance and watchful waiting to assist them in dealing with the natural concerns about “living with an active cancer”?

Absent such information, all we have is opinions and speculation, which is of course well within the realm of politics. But it doesn’t help when those at Politico and other media don’t appreciate important details.

The single great advantage of active surveillance as opposed to immediate definitive therapy for early stage, localized prostate cancer is that it allows the patient and his doctor to defer or delay any decision about immediate invasive therapy (for 6 months, or 6 years or even forever), which, as an added benefit, means the patient can defer or at least delay any risk for the known adverse effects of such invasive therapy.

Active surveillance may well be an outstanding management strategy for a group of men who can defer therapy indefinitely (because they do, in fact, have indolent disease) or until they die of some other cause (despite slowly progressive disease). Then they will be able to defer their risks associated with definitive treatment indefinitely too. At present we do not know how best to identify this group of men or to what degree active surveillance is associated with better, worse, or similar outcomes compared to invasive therapy over time, and we probably won’t even begin to understand this until the results of the ProtecT study are available at least 5 years from now.

Given the little we know about Senator Wyden and his diagnosis, his recent decision to have surgery seems entirely appropriate (and probably no worse or better than any other). Five or 10 years from now, we may know more, and we may be able to say with greater certainty that Senator Wyden was well or poorly advised or that he made a good or a bad decision. At present, we just don’t know … and no amount of opinionated speculation is going to help. We don’t have the data to improve the decision processes.

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