THE "NEW" PROSTATE CANCER INFOLINK

In one of the more important lectures at the upcoming annual meeting of the American Urological Association, starting in Orlando in a couple of weeks’ time, Dr. Peter Albertsen will be reviewing contemporary recommendations on the practice of active surveillance (AS) for men with low- and very low-risk prostate cancer.

Some 20 years ago now, in the mid-1990s, Dr. Albertsen was a highly controversial figure in the prostate cancer community because he had started to publish data suggesting that older patients with a Gleason score of 6 or less appeared to have minimal survival benefit as a consequence of early, first-line treatment for prostate cancer. (See for example this seminal paper that appeared in the Journal of the American Medical Association.) It took several years for many members of the urology and the prostate cancer community to accept the accuracy and clinical importance of Albertsen’s early data (although there were certainly those to whom it made perfect sense early on).

It is gratifying to see Dr. Albertsen receiving the recognition, in the past few years, for all his early hard work — even though he received much more notoriety for this than kudos  back in the mid-1990s.

A summary of Dr. Albertsen’s proposed lecture at the AUA this year is available on line on the AUA News web site (but you do have to be a subscriber or another type of approved individual to be able to see the original). For those well familiar with the evolving principles of active surveillance, his recommendations are not controversial. But Dr. Albertsen does make some important points that are emphasized below.

According to Albertsen, “most advocates of active surveillance” would argue that the following men are candidates for this form of management today:

• Men with
  • A normal digital rectal exam result (i.e., clinical stage T1)
  • No sign of any Gleason pattern 4 disease in any biopsy core
  • A PSA level of 10 ng/ml or lower
  • A PSA density of 0.15 ng/ml/g or lower
  • A relatively low tumor volume
    • No more than 2 positive biopsy cores out of 10 or 12
    • No more than 50 percent of any one core being cancerous tissue
    • No more than 3 mm  of continuous cancerous tissue in any one core

These criteria define a set of men, diagnosed with early stage, low-risk prostate cancer, who are “unlikely to experience [prostate cancer] progression within a decade.”

Albertsen also notes that

• Gleason score is the single most powerful predictor of disease outcome.
• Gleason score carries more weight than tumor volume.
• It is only, ultimately, the patient himself who can effectively evaluate the level of risk he is willing to accept and act accordingly.

In addressing the issue of monitoring over time, Albertsen states that:

• There is no consensus yet on appropriate monitoring strategy.
• Most clinicians repeat patients’ serum PSA tests every 3 or 4 months.
• Most clinicians will  conduct a repeat biopsy within 1 year of initial diagnosis.
• Most clinicians now try to incorporate some form of imaging  (with pelvic MRI).
• Many clinicians will want to carry out further repeat biopsies at 2- or 3-year intervals.

Last but not least, here is a summary of some comments that Albertsen makes about the practical application of differing tools used in the monitoring of men on active surveillance:

• “The ability of serial PSAs to identify men likely to have progression is unknown.”
• “Repeat PSAs often have considerable variation and, therefore, a single PSA should rarely trigger intervention.”
• “Data from Johns Hopkins have shown no correlation between between PSA doubling time and adverse pathology on subsequent radical prostatectomy.”
• “Data from the Royal Marsden Hospital [in the UK] suggest that a PSA velocity > 2.0 ng/ml/year is associated with disease progression.”
• “Transrectal ultrasonography is not sufficiently sensitive to identify disease and monitor progression.”
• When it comes to using MRI scans to monitor progression, “standard T1- and T2-weighted sequences are insufficient” (but other more advanced forms of MRI do appear to have significant value and potential)
• “Small lesions, especially those residing in the transition zone [of the prostate] can be difficult to read consistently” on even high-quality MRI scans.

Dr. Albertsen concludes his article with the following statement:

Most men harboring low volume, low grade prostate cancers are unlikely to experience disease progression. Active surveillance offers these men an approach that allows them to balance the risk posed by treatment against the risk posed by disease progression.

While The “New” Prostate Cancer InfoLink would encourage the urology community to develop and publicize some clear, standard guidance on the appropriate role and procedures to be used in the application of active surveillance in the management of early stage prostate cancer, we also feel that Dr. Albertsen has laid out a fairly good set of general principles here that can be applied to a very high percentage of men being diagnosed with low- and very low-risk disease today.

Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk | Tagged: active suirveillance, candidate, monitoring, reccommendation |