THE "NEW" PROSTATE CANCER INFOLINK

At least one paper has stated that some 40 percent of men diagnosed with low-risk prostate cancer here in the US are now being initially managed on active surveillance. If active surveillance is being done properly, this is a good thing! However, …

What “being done properly” is when we refer to active surveillance is still something of a moving target and depends on a whole variety of different factors, including:

• The patient’s age, health status, and individual risk level
• The patient’s level of concern about his risk for progression over time
• Whether the patient’s physician and the patient himself have access to high quality multiparametric MRI (mpMRI) scanning capabilities and associated MRI/TRUS-fusion biopsy technology
• The experience of the individual physician in managing patients on active surveillance

A factor that can be critical to all of this — and which has yet to be fully resolved — is the role of mpMRI in three particular scenarios:

• The decision to place the patient on active surveillance in the first place
• Whether serial mpMRI scans can or should be used to monitor the patient over time (and if so how often an mpMRI should be given)
• Whether serial mpMRIs can actually “replace” serial prostate biopsies in the monitoring of men on active surveillance

So for those who are interested in a review of the current status of research into these issues, we recommend a recent review by Alam et al. from the Johns Hopkins group. The paper is entitled, “Active surveillance of prostate cancer: current state of practice and utility of multiparametric magnetic resonance imaging“, and the full text of the paper is available at the link provided.

Some readers may find the review to present a rather cautious and “conservative” mindset as to the application of mpMRI in the management of men on active surveillance. The basic “take away” points made by the authors are the following:

• “Active surveillance (AS) is a management strategy in which men with favorable-risk prostate cancer avoid or delay immediate intervention in favor of close monitoring.”
• “Traditionally, monitoring on AS has consisted of frequent digital rectal examination, serum PSA testing, and transrectal ultrasound-guided biopsy. New tools such as multiparametric magnetic resonance imaging (mpMRI) are being actively incorporated into previously reported protocols.”
• “Current data have not yet identified a favorable subset of men with intermediate-risk disease. Therefore, these patients should be counseled appropriately about the potentially increased risks of AS.”
• “There are substantial limitations to our understanding of mpMRI in the AS setting, as the majority of data have been obtained from retrospective experiences in which mpMRI was not uniformly applied.”
• “Current data demonstrate that mpMRI alone does not preclude the need for prostate biopsy. Furthermore, systematic biopsy should continue to be performed at the time of targeted biopsy in most settings.”

With regard to the fourth bullet point just above, the authors refer readers of an article about the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) checklist (see Moore et al.), which is a standardized protocol developed by a European School of Oncology Task Force for reporting outcomes using mpMRI in AS.

What readers need to appreciate is that — from a researcher’s perspective — the important issue is to be able to achieve two quite different and potentially conflicting ideals:

• That no man placed on active surveillance ever gets a forms of prostate cancer that can progress to metastatic disease before it can be cured
• That no man started on active surveillance is advised to have invasive treatment that he doesn’t really need

The individual patient is going to look at this very differently at the present time. Some will be more willing to take risks and stay on active surveillance because they value their quality of life above their risk for progressive prostate cancer. Others will be more willing to take risks with their outcome from one of many different forms of treatment because of their fear of progressive prostate cancer.

It is going to take us a while to find common ground among all parties about “the right” ways to apply mpMRI along with other tests in the management of man on active surveillance. After all, some men might well need to be on active surveillance for 25 years and longer.

Filed under: Diagnosis, Management, Risk | Tagged: active, mpMRI, MRI, multiparametric, surveillance |