“Active surveillance: protecting patients from harm”

If you want to get a current update on the management of patients on active surveillance, you need to listed to/watch this presentation by Dr. Lawrence Klotz on the UroToday web site. But you will need 45 minutes.

There are few physicians around the world who have as much experience in managing men on active surveillance as Dr. Klotz and his colleagues at the Sunnybrook Center near Toronto, Canada. They have bult their experience carefully over time. They have carefully integrated and studied the value of techniques like multiparametric MRI scans, MRI-guided and MRI/TRUS fusion-guided biopsies, molecular testing, etc. into the management protocols that they use.

The current work of Dr. Klotz and his colleagues is focused — laser like — on trying to  better ensure that we can and will be able to identify with great accuracy all men who have any amount of Gleason pattern 4 or other molecularly definable higher-risk disease so that appropriate treatment can be offered to those patients as early as possible. However, …

Klotz and his colleagues continue to believe that active surveillance can still be a reasonable option for many patients with “favorable” forms of intermediate-risk prostate cancer, especially if they have other co-morbid conditions that could lead to their deaths within the next 10 to 15 years.

11 Responses

  1. Doc Klotz is a great man!!!

  2. Is there a standard for a DRE? One urologist DRE recorded the approximate size of prostate, any nodules, and smoothness of prostate. A second urologist said you have a small prostate. What should a DRE consist of?

  3. There is no “standard” way to do a DRE because it depends on exactly what the doctors doing the DREs are seeking and expecting based on other information, and it may also depend on the physiology of the patient and how far and therefore how much the doctor can actually feel. DREs can also be relatively more of less “vigorous”.

    A doctor should always tell you if he or she can feel any nodules or rough spots (since those are potential risk factors) for prostate cancer. He would also normally tell you if the prostate felt enlarged and “spongey” since that would be indicative of benign prostaticg hyperplasia (BPH). However, what the two doctors you refer to told you do not necessarily contradict each other. It would appear that you have a relatively small prostate with no indication of any nodules, rough spots, or tissue suggesting BPH.

  4. That helps, thank you.

  5. Always good to keep up with what the high priest of AS is saying; thank you. I have looked and I think his work is not eligible for the Nobel. But if I were in the requisite Chair, I would try anyway.

    He has said separately that in some cases they might be “guilty of having under-treated” and he obviously feels each “loss”. He would want to treat me in light of my 23% risk of detected (so 23% is an underestimate) metastasis before age 75.

    That is real fear. But as Klotz pointed out, radical treatment cannot make it go away. Likewise, as discussed lately below the “Treating the psychosocial and emotional impact of prostate cancer” post, I am stuck with that fear for life and the corresponding “hope” of dying of something else.

    As I clumsily tried to point out, the whole field needs to move from fear-based medicine to hope and I think that is what is so attractive about Klotz.

    But: I noted his belief that statins and metformin (my regime) slow progression and the only possible result of that is to push his black area to the right. All progress depends on the unreasonable man, so there I sit, waiting for the tide to come in and him to downgrade my 23%. My own guinea-pig in a statistically irrelevant RCT with n = 1.

  6. An outstanding and honest summary of the current state-of-the-art for active surveillance for prostate cancer. I’ve made a “tiny URL” link for the video to share with support groups: http://tinyurl.com/klotz2017as

  7. PS: There is a key element missing in Klotz’s tree analysis and I think it could at least be well estimated by meta-analysis. Namely, the rates of progression following “gold-standard” (RP) treatment. The numbers he loses are not all the result of AS: only the delta to the other number are. Odd that he does not make more of that.

  8. Bill:

    I am pretty sure that this is deliberate on Klotz’s part. I think he would make the point that this is an “intent-to-treat” cohort of patients, and therefore regardless of what happened after a patient came off AS, he is still technically a “failure of AS” even though he may not “really” be. After all, we have no idea how many of the patients who came off AS voluntarily actually had surgery, or radiation, or whatever, as their next form of “treatment”. Klotz may or may not have those data, but he probably doesn’t have it for all of the patients.

  9. I think we might be miscommunicating again. I apologise for either not being clear in writing or not being good at reading. My point is that for a newly-diagnosed man considering AS, the key data point is not how many people with his grade go on to metastasis under AS, it is how many of his grade go on to metastasis under AS _compared to_ how many go on to metastasis following treatment.

  10. Dear bgollum:

    I understand the distinction that you are making entirely, but the problem is that those data may be very difficult to obtain accurately because (for example) if a man has been on active surveillance at Klotz’s clinic for 3 years and then he decides to have treatment (even though Klotz is telling him he doesn’t need it) and he goes elsewhere to get that treatment, Dr. Klotz and his colleagues will have no information about whether that man went on to have metastasis or die of prostate cancer.

    Given the very small numbers of men in Dr. Klotz’s series that actually went on to have metastasis or to die of prostate cancer at a median of > 10 years of follow-up, even a couple of men whose data aren’t available might radically change the difference you are referring to. And there would also (potentially) be no information whatsoever about the (also very small number of) men who actually die as a consequence of complications of surgery for prostate cancer.

  11. There still may be room for misinterpretation. Nobody should have metastasis while under active surveillance in a program like Dr. Klotz’s because, if done properly, the advance of their cancer would have been detected and they would have moved to definitive treatment. What would be of interest would be comparing the rate of metastasis, stratified by cancer risk factors and type of treatment, of those who deferred treatment by active surveillance to those who had immediate treatment. Might be difficult to compile the appropriate data …

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