Other items from the annual meeting of the AUA

A combination of travel and other commitments made it difficult for your sitemaster to complete his summaries of significant information presented at this year’s annual meeting of the American Urological Association (AUA), so here’s the final wrap-up.

In addition to the prior articles already provided:

(1) There is an excellent article in The ASCO Post dealing with new data presented at the AUA meeting on the effectiveness and safety of active surveillance in the management of men with low-risk prostate cancer. The article addresses four studies in particular:

  • A paper by Tosoian et al. (abstract no. PD6-04) that gives long-term survival data from the Johns Hopkins series of nearly 1,300 men on active surveillance as being
    • 93.2 percent overall survival at 10 years
    • 68.7 percent overall survival at 15 years
    • 99.9 percent prostate cancer-specific survival at 10 years
    • 99.9 percent prostate cancer-specific survival at 15 years
    • 99.4 percent metastasis-free survival at 10 years
    • 99.4 percent metastasis-free survival at 15 years

    Unsurprisingly the authors conclude that active surveillance seems to be an appropriate and safe management strategy for carefully selected men with favorable-risk prostate cancer, and most especially for those men with very low-risk disease as defined by the so-celled Epstein criteria.

  • A second study was a paper (abstract no. MP42-04) based on the data by Alam et al., again from Johns Hopkins, that we have already discussed elsewhere, and that deals with the decreasing risk of re-classification of men on active surveillance on repeat biopsies.
  • A third paper (by Shelton et al.; abstract no. MP4-03) dealt with the significant evidence of increasing acceptance and application of active surveillance in community practices. This paper reported that 70.2 percent of very low-risk patients and 39.2 percent of low-risk patients were now receiving initial management on active surveillance among eight large urology group practices. It should be noted that the percentages of very low- and low-risk patients receiving initial management with active surveillance in Sweden are significantly higher, based on other data presented at the meeting. However, these data are still very promising in terms of the adoption and acceptance of active surveillance as a first-line management strategy here in the USA.
  • The fourth paper discussed in The ASCO Post article was one by Loeb et al. (abstract no. PD34-11) pointing out that there is still no broadly accepted and standardized protocol for the management of men on active surveillance. The “New” Prostate Cancer InfoLink hopes that some significant progress on defining such a protocol or protocols can be achieved in the next couple of years.

(2) There was a great deal of discussion at this meeting about the use (and arguably the over-use) of testosterone therapy in men with “less vigor” as they aged. However, from a prostate cancer perspective, there was an important paper by Boyle et al. discussing testosterone supplementation and the possible increase in risk for prostate cancer. This is discussed at length in an article on the Medscape web site. Boyle and his colleagues make two key points based on  a detailed and sophisticated meta-analysis of the currently available data:

  • There is no indication on the basis of the available data that testosterone supplementation is associated with an increased risk for diagnosis with prostate cancer, but …
  • The average follow-up time for men in the currently available studies, and thus included in the meta-analysis, is a great deal shorter than the 15- to 20-year follow-up that is really needed to make any definitive statements about such risk, and there are definitely still reasons to be concerned about the effects of testosterone supplementation on risk for prostate cancer diagnosis

In other words, individual patients and their doctors do need to be conscious that we still don’t have a good appreciation of the long-term risks for diagnosis of prostate cancer that may (or may not) be associated with the use of testosterone supplements.

(3) New data presented by Freedland and colleagues provide conflicting data about the risks and benefits of the early use of androgen deprivation therapy (ADT).

In one paper, Freedland et al. (abstract MP82-15) offer data suggesting that men with biochemical recurrence after initial surgery actually benefit (in terms of their overall survival) from initiating ADT before their PSA level reaches 10 ng/ml, and that this benefit was stronger when ADT was initiated before patients’ PSA levels reach 5 ng/ml. However, in another paper (as reported in Renal & Urology News) the same group of researchers apparently showed almost exactly the opposite effect — that men under 65 years of age with biochemical recurrence post-surgery have a decrease in overall survival if they initiate ADT when their PSA is ≤ 5 ng/ml! Quite what one is meant to make of conflicting data like this is hard to say. The “New” Prostate Cancer InfoLink is of the opinion that we have a way to go before we really understand when it is most appropriate to initiate ADT in individual patients with progressive prostate cancer.

5 Responses

  1. Myriad presented a paper (I just read the news release) on a fairly large study they did on the role of Prolaris in identifying and managing active surveillance. Obviously they have a profit motive in doing such studies. However, did you see it, and if so, what do you think? It seems to me that this test (and the similar Genomic Health test) would have significant value in identifying patients who, although they look like candidates for AS, actually have an aggressive cancer. Having such a tool would seem to me to give patients and doctors significantly more confidence in proceeding down the AS path. I know you have been skeptical in the past on this. Any change in opinion as more studies on the use of the tests are published?

  2. Excellent. Thank you.

  3. Doug:

    I have never been skeptical about what these tests can do when they provide results based on data from groups of patients. My skepticism is about what they offer for an individual patient at a point in time. Almost every one of the genomic test manufacturers presented new data using their tests at the AUA meeting. However, I think that what you are actually referring to is a media release issued by Myriad Genetics about a paper just published in the Journal of Urology, based on 582 patients, and I haven’t had a chance to look at that paper yet. I will see if I can do so later today. The media release is at best “vague” in my opinion.

    The use of these tests is a matter of considerable interest to the National Comprehensive Cancer Network in respect to the guidelines on the diagnosis of prostate cancer. At present all that the NCCN is saying is that such tests “have significant potential”. I would tend to agree with that, but one of the issues with all of these tests is whether the tests are being run on the most aggressive area of tumor in an individual man’s prostate. If the right area wasn’t biopsied in the first place, then the test won’t be able to give a good answer anyway!

  4. Doug:

    Here is a link to the actual abstract presented by Cooperberg et al. that is referred to in the previously mention media release. These are data from yet another retrospective analysis. They do not tell us how accurate Prolaris is when used prospectively to project risk in a series of men who are actually then managed on active surveillance. These data are intellectually interesting but clinically rather meaningless. The only way we will know if these tests really work to predict whether a man is a good candidate for active surveillance is when such men are tested and then followed (potentially for years) actually on active surveillance

  5. Re item (1),

    Based on “68.7 percent overall survival at 15 years” and “99.9 percent prostate cancer-specific survival at 15 years”, that means that an overall death rate over 15 years of 100% – 68.7% = 31.3%, with 0.1% due to prostate cancer, yielding an overall death rate for the group that is not due to prostate cancer of 31.2%, with an 0.1% death rate due to prostate cancer. So, 31.2%/0.1% = 312 deaths, at 15 years for every death due to prostate cancer. Right?

    Pretty good odds for those choosing active surveillance!

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