This morning we have a series of four more prostate cancer-related summary reports from the 14th annual meeting of the Society for Urologic Oncology (SUO) available on the UroToday web site (which is freely accessible to patients, but you do have to register to access it).
The “Session Highlight” reports from yesterday’s sessions address a series of issues relevant to the selection and management of men for inclusion on active surveillance (AS) protocols:
- Are biomarkers useful in selecting/monitoring patients on AS? is based on a presentation by Reic Klein, MD, of the Cleveland Clinic. Dr. KLein apparently argued — with some justification — that, within traditional patient risk groups, there is a spectrum of risk and significant overlap of risk between the traditional risk groups can be observed. He want on to argue that the advantage of some of the newer biopsy-based biomarkers is that they can help to individualize risk for a particular patient and distinguish patients within risk groups with more indolent or aggressive disease.
- Race and the selection of patients for AS is based on a presentation by Edward Schaeffer, MD, of Johns Hopkins in Baltimore. Dr Schaeffer reviewed data previously published suggesting that AS is less likely to be an appropriate management strategy for African American men than it is for Caucasians. One possible reason for this has to do with tumor location. Dominant tumors in African American men seem to be more likely to be located anteriorly than in Caucasians and so they are more likely to be under-sampled on standard transrectal prostate biopsy.
- Vagaries in the interpretation of prostate biopsies is based on a presentation by Scott Lucia, MD, of the University of Colorado in Denver (a uropathologist). Dr. Lucia stated that — in his opinion — prostate biopsy is limited in its ability to identify patients with truly low-risk disease for active surveillance and that we still need improved imaging techniques and/or biomarkers to more accurately stratify risk for individual patients.
- Can MRI replace prostate biopsy or not? is based on a presentation by Maxwell Meng, MD, of the University of California, San Francisco. In answer to this question, Dr. Meng appears to have proposed an answer that said, “Yes, sometimes, under the right circumstances.” He noted that, based on currently available information, the best way to incorporate MRI into the diagnostic process for potential AS candidates may be by using an initial MRI-targeted biopsy (i.e., some type of MRI/TRUS fusion biopsy) to properly identify clinically significant tumors that might exclude a patient from consideration as a good candidate for active surveillance.
These reports were written by either Timothy Ito, MD, or Jeffrey J. Tomaszewski, MD , of the Fox Chase Cancer Center in Philadelphia, Pennsylvania.
The need for accurate assessment of appropriate candidates for inclusion on active surveillance protocols is clearly a priority. However, The”New” Prostate Cancer InfoLink is still concerned that there could be an over-emphasis on immediate treatment for men with some forms of intermediate-risk prostate cancer who have a reasonable life expectancy of 10 to 15 years or more but might reasonably consider deferring treatment for a while.
The treating community still seems (to us) to focus more on “getting rid of the cancer” than they do on the actual and potential impacts of treatment on the quality of life of the patient with lower-risk forms of prostate cancer. Finding the right risk balance for the individual patient and helping that patient come to the right decision for him as an individual is an increasingly critical factor in the management of early stage prostate cancer — particularly when active surveillance is one of the management options that should be under consideration.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Uncategorized | Tagged: ctive surveilance, identification, patient, selection |
THE "NEW" PROSTATE CANCER INFOLINK 
Hello and thank you for your efforts to inform us all who either have this disease or are family members of one who does.
My brother was diagnosed with prostate cancer that had metastasized on a minimal level (according to him). That was in October of 2011 — so he is going on a little over 2 years. He has been on androgen deprivation therapy. He studied and eats foods according to what he has learned are best for his survival and is very health conscious. He also believes in the body being able to heal itself and the power of positive thinking. Naturally we all are praying for him. The couple times I have asked about how he is doing, he tells me fine and that he doesn’t care to talk about it. I think he feels that is negative (or maybe he is trying to deny things).
Can you tell me what we can expect if he does not have a miraculous remission. In general terms of course. I understand a prognosis is impossible and un-realistic in an e-mail and based on such limited information. I am just getting more concerned as time goes by and since I am not a doctor it is hard to follow the site info sometimes. I seem to have gleaned that he may be nearing the time where ADT may start to become ineffective. Any thoughts you have would be appreciated.
Thanks again for your site. It is very informative.
Dave
Dear Dave:
Alas, it is completely impossible to give any sort of meaningful projection about your brother’s situation without a great deal more very specific information (including things like his age, his Gleason score at diagnosis, his clinical stage at diagnosis, his PSA level at diagnosis, the degree of metastasis, etc., etc.).
There is, in any case, enormous individual variation in the ways that men with minimal, asymptomatic, metastatic prostate cancer can respond to ADT. Complete remissions do, rarely, occur. On the other hand, most such men will progress to castrate-resistant prostate cancer over time … but that “time” can be as short as 6 months or as long as 25 years, so trying to make any sort of meaningful projection in your brother’s case without more data is simply not a real possibility.
The other thing that you need to recognize as important here is what I see as your brother’s desire to simply go on “leading a normal life”. As a society we tend to be not very good at managing our relationships with those who we see as having a potentially terminal illness. Your brother has clearly decided what he needs to do to maximize the length and quality of his life, and he wants to be able to control the degree to which others are privy to the associated information. I think you need to be able to sympathize and empathize with his perspective and just trust that he will tell you and other family members if and when he has any other important update that he wants to share with you.
For a lot of cancer patients, every question about their health status is a “loaded” question, coming as it does with the implied, “And how much longer should I expect you to be around?” I am sure that you can imagine that that is a problem if you are on the receiving end. Your brother seems to me to just not want to have to deal with any of this until he is either ready to or feels that he has to. You and your family probably need to find a way to just accept this and let your brother “keep the ball” until he is ready to make the next pass (to use a soccer or basketball analogy). Such a strategy may actually help him to “open up” a little if he knows that when he does you will just say something like, “Oh. I see. OK. Thanks for the update. Do let me know if there’s anything I can do to help,” and then go back into waiting mode again.