Differing family histories and the role of active surveillance

Two recent papers in BJU International have suggested that — at least for most Caucasian men — there is no current evidence that a family history of prostate cancer should be a disincentive to initial management on active surveillance for men diagnosed with low-risk prostate cancer.

The two relevant papers are ones by Goh et al. and by Telang et al. In the first, the researchers looked in detail at the family history and the genetics of a cohort of 471 men being managed on active surveillance at the Royal Marsden Hospital just outside London in England. In the second, Telang et al. reviewed data from six research publications about the relationship between family history and prostate cancer progression.

Of course one of the problems here is that “family history” is varied. A newly diagnosed patient who had a father and a brother who were both diagnosed with prostate cancer which went on to metastasize and lead to their deaths has a very different family history to patient whose father was diagnosed with a Gleason 6, low-risk form of prostate cancer at age 69 and got it treated 15 or so years ago (when almost everyone with such a diagnosis was getting treated). We now know that men with such a low-risk form of prostate cancer can be monitored with a very high degree of probability that they will be at extremely low risk for metastasis or prostate cancer-specific mortality.

Thus, the real question here is going to be, what does a man do if he has been diagnosed with low-risk prostate cancer but he does indeed have a family history that includes a father or brother who has metastatic disease or has died of prostate cancer.  Does that type of family history change his risk?

The answer seems to be that we don’t have a good answer to that question yet. Your sitemaster believes that a man who finds himself in that situation today would be wise to make as sure as he could, relatively soon, that his cancer really is low risk — by having an MRI and then an MRI-guided or MRI/TRUS fusion-guided biopsy as well as one of the genetic/genomic tests to assure that his cancer really is low risk (or not). If it is indeed low risk after such tests, then active surveillance (with rigorous and regular monitoring) would probably still be a very good idea, and if it isn’t low risk after those tests, then one would be wise to have treatment relatively soon.

Having said that, it was also clear from the paper by Telang et al. that, in the case of men of African-American race, family history might be a key factor in the decision whether or not to apply active surveillance, and that more research is going to be necessary to come to accurate conclusions in this set of patents.

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