Expert opinions on active surveillance and surgery for localized prostate cancer

At least some readers of this news-blog may be interested in two items posted earlier today on the Medscape Oncology web site.

First, the full text of an article by Lawrentschuk and Klotz (entitled “Active surveillance for low-risk prostate cancer,” and reproduced from Nature Reviews Urology) offers a thorough overview of the current state of knowledge about the role of active surveillance in the management of localized prostate cancer. Obviously this article reflects the authors’ strong beliefs about the value of active surveillance for appropriately selected patients. However, The “New” Prostate Cancer InfoLink believes that this review offers good insight into the risks and benefits of active surveillance and the future potential of this forms of management.

In the second of these two items (“Is robotic surgery overhyped?“), Dr. Gerald Chodak discusses on his video-blog the differences between the ways that minimally invasive radical prostatectomy (MIRP) — and in particular the robot-assisted form of laparoscopic radical prostatectomy (RALP) — are promoted to patients and the actual data available that compare outcomes after RALP to outcomes after open retropubic and open perineal forms of radical prostatectomy. To all intents and purposes, Dr. Chodak’s question is whether the way hospitals and some in the urology community are currently promoting RALP to potential candidates for this type of surgery is justifiable in light of the available data.

One has to be a member of Medscape to gain access to this material, but registration is free and straightforward, and one can opt out of any promotional e-mails from this medical information service provider if you wish to do so.

5 Responses

  1. I’m not too sure that I agree with everything in the piece. For example the opening sentence is:

    Active surveillance is now an accepted management strategy for men with low-risk localized prostate cancer, in recognition of the knowledge that the majority of men with such cancers are likely to die from other causes.

    Is it really an accepted management strategy? Are newly diagnosed men told that this is one of their options? Maybe in some cases, but I am still getting mail from men with “low-risk localized prostate cancer” who have been told that surgery is their only option and the sooner the better. Men with “low-risk localized prostate cancer” tell their stories on the Yana site with no mention of being told about AS (active surveillance) as an option let lone that it is an accepted management strategy.

    After all these years when watchful waiting and AS were subjects which attracted attacks and abuse when trying to discuss them as logical choices for some — not all men — it warms the cockles of my heart to read a paragraph like this one:

    Prostate cancer screening using digital rectal examination (DRE), PSA testing and biopsy leads to the detection of disease that is not clinically significant in many patients, meaning that if untreated the cancer would not pose a threat to health or cause death. Treating men with clinically insignificant tumors involves the risk of unnecessary morbidity. Hence, AS seems to be a solution to the widely acknowledged problems of overdiagnosis and overtreatment that inevitably accompany the early detection of prostate cancer. Furthermore, prostate cancer has a long lead-time before it becomes clinically apparent. As such, AS is an excellent way of buying time until the aggressiveness of disease in any particular patient can be identified, reserving radical treatment for those in whom it is necessary.

    And this one:

    In summary, AS for favorable-risk prostate cancer is feasible and seems safe according to the 10–15 years of available data. AS provides an individualized approach to low-risk prostate cancer based on the demonstrated risk of clinical or biochemical progression over time; large series of AS have revealed that the likelihood of dying as a result of causes other than prostate cancer is far greater than disease-specific death. Uncertainty remains regarding the long-term impact of delayed treatment in men reclassified as higher risk after a period of observation and repeat biopsy. Results from prospective, randomized trials comparing AS to radical treatment and larger cohort studies are required, and are currently underway. Men with favorable-risk disease should be offered AS as a possible treatment option, and educated regarding the risks and benefits of this approach.

    Couldn’t have put it better myself!! Yes, there is uncertainty associated with AS, but show me any other therapy where there is certainty. It simply doesn’t exist any more than certainty exists in or any other aspect of life. We each have a theoretical life span that has a range starting a few minutes or hours from now (heart attack, accident, natural disaster) to age 120 which at present represents the greatest possible age for anyone to live to. None of us has any real idea when, in that range we will pass on.

  2. Terry:

    When the NCCN guidelines here in the USA say that active surveillance is the only recommended management strategy for men over 65 years of age with low- and very low-risk disease, I think it is fair to state that “Active surveillance is now an accepted management strategy” for such men. Are all physicians following these guidelines? No. Of course they aren’t. Please see this article on bloodletting and the management of prostate cancer previously referred to on this site.

  3. Thanks for that excellent link, Mike.

    As ever, I’ll bow to your local, extensive knowledge regarding the implied acceptance of the NCCN guidelines. I have seen commentary from some well-known medical people saying that the guidelines are not based on any sound studies and it is still as rare as rocking horse doo to see any of the men who communicate with me saying anything about suggestions of AS from any of their medical advisors.

    Maybe I’m just getting impatient as I age: maybe despite what Dr Thomas Stamey had to say some years back (I believe that when the final chapter of this disease is written, which is unlikely to be in my lifetime, never in the history of oncology will so many men have been so overtreated for one disease) the over-treatment might slow down in my lifetime.

  4. Terry:

    Those who think that active surveillance is over-hyped will continue to argue against its use for some considerable period of time … and it is possible that the ProtecT study will help to show us that its value is limited to some specific subset of patients.

    What is certainly true, however, is that I am seeing more men who are stating that their doctor has recommended AS. Is it anywhere close to 25% of all diagnoses? Not yet. These things take time. I am also aware that there are a lot of men whose doctors recommend AS but the patients have a hard time accepting this recommendation and insist on treatment. Not all over-treatment is driven by the medical community.

  5. Good point. I am corresponding with a young man of 46 who has a “very low-risk” diagnosis but who is determined to have treatment despite all the verifiable evidence I gave him when he said he was interested in AS.

    A key factor is that he was told, in writing, by a well-known, high-profile doctor that Studies indicate that the younger a man is when diagnosed, the higher the chances are of his cancer being aggressive.. I suggested that the doctor be asked to provide details of these studies, but (alas!) there has been no response. It is the word of an expert that is driving his decision.

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