Wednesday, December 7, 2022

When To Stop Active Surveillance For Prostate Cancer

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Natural History And Genetic Features Of Low

What is Active Surveillance for Prostate Cancer?

The chief dilemma in managing clinically localized prostate cancer stems from the heterogeneity of the disease. Prostate cancer arises from genetically altered prostate epithelium and slowly progresses over several decades. Given its features of multifocality and tumor heterogeneity, the course of prostate cancer is difficult to predict. Men may live their entire natural life without having any symptoms from prostate cancer. Zlotta et al confirmed this hypothesis when they prospectively compared tissue obtained during autopsy from prostate glands in both a Caucasian and an Asian population. Prostate cancer was found in a similar proportion of men in both groups. Also, more than 50% of the cancers in the Asian group had a Gleason score of 7 or greater. The natural history of this disease, which is characterized by slow progression, makes it possible for active surveillance to be an effective management strategy.

The key point here is that most Gleason 6 cancers have innocent genetic features and no risk of metastasis. Thus, in the absence of higher-grade cancer, there is little indication for treatment in most patients.

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Outcomes Of Active Surveillance

Observational studies

Multiple groups worldwide have reported the results of prospective cohorts that provide data about the clinical course of patients managed with active surveillance. Data and outcomes from those groups consistently show a low rate of progression to metastatic disease or death from prostate cancer. The first study of active surveillance was started by researchers at the University of Toronto in 1996. This single-arm cohort study included 993 men, 740 with low-risk disease and 253 with intermediate-risk disease who had significant comorbidity or a life expectancy of less than 10 years. Among the 819 survivors, the median follow-up was 6.4 years. Altogether, 2.8% of the patients developed metastatic disease, and 1.5% died of prostate cancer. In the group with low-risk disease, the metastasis-free survival rate at 10 and 15 years was 96% and 95%, respectively. In the group with intermediate-risk disease, the metastasis-free survival rate was 91% and 82% at 10 and 15 years, respectively. Importantly, the presence of Gleason pattern 4 disease at diagnosis increased the rate of metastasis by 3.75, despite close monitoring and treatment for progression.

Randomized trials

Does My Age Influence Whether Active Surveillance Is The Right Choice For Me

Younger men will live longer with their cancers, and thus have a higher likelihood that their cancer could progress. However, younger men whose cancers appear to be less aggressive may be able to stay on Active Surveillance longer. Younger men also have more to lose when it comes to quality of life as they often have better erectile and urinary function than older men.

Active Surveillance may also be more appropriate for men who are currently battling other serious disorders or diseasessuch as significant heart disease, long- standing high blood pressure, or poorly controlled diabetes. In a patient with other health issues, the patient and his doctors might feel that performing invasive tests or treatment would cause more harm than benefit. For these men, their treatment plan would of course help manage any symptoms that occur due to advanced disease. There are also some men with favorable intermediate risk who may be good candidates for Active Surveillance.

Some physicians also administer commercial genetic testssuch as Decipher®, ProMark®, and Prolaris®that may be helpful in determining if you are a good candidate for Active Surveillance. Researchers are working to define the best ways to use these tests.

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Active Surveillance Testing Schedule

Medical experts offer various recommendations regarding frequency of testing and when to start treatment during active surveillance. The American Society of Clinical Oncology recommends the following periodic evaluations while under active surveillance for prostate cancer:

  • PSA testing every three to six months

  • A digital rectal exam at least once a year

  • A prostate biopsy at least every two to five years

If test results or symptoms indicate the cancer is progressing, treatment is recommended with the intention of curing the disease.

Is Active Surveillance Right For You

Active Surveillance for Prostate Cancer Could Be Better Option

In deciding if youre eligible for active surveillance, your physician will consider your:

  • Gleason score .
  • PSA results, the volume of cancer found on biopsy and the risk category of your cancer.
  • Overall health and life expectancy.

To be eligible for surveillance, you have to meet two criteria: One is the biological criteria, meaning you have to have the right tumor, Dr. Haywood explains. The second is you have to have the right psyche. Active surveillance is not for everyone.

In making your decision about active surveillance, ask yourself: Can you commit to repeated testing , which can cause some pain and carry a risk of infection?

And carefully assess whether you can live with the idea of having untreated cancer. In the study presented at the 2019 ASCO meeting, few men expressed regret about choosing active surveillance, but 16% of them converted to curative treatment within the first two years. The reason? The study says it was likely driven by patient anxiety, not disease-related factors.

Still, active surveillance remains a good option for the right men. Just be sure to ask your doctor what to expect.

When someone is newly diagnosed with prostate cancer, the first question they should ask ought to be not whats the best treatment, but does the cancer need treatment? Dr. Haywood advises. Thats what I would encourage any patient to ask.

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Playing With A Loaded Gun

It was the concern about overtreatment that originally encouraged wider adoption of AS. Now, there is a different concern as newly available 5+ year data suggests that some urologists keep men on AS beyond the window for curative treatment. Without diagnostic certainty about which cell line is growing in a mans body, there is always the possibility that hes harboring a disease that does not generate a high PSA but which has the capability to progress rapidly, spread beyond the gland and become lethal. In this respect, AS is like playing with a gun that holds an unknown bullet.

Tosoian et al. assembled data from various published AS studies. Within 5 years of starting AS, the proportion of men who are upgraded by biopsy and receive whole gland treatment ranges from 24-50%. Of four studies that followed treated patients, biochemical recurrence ranged from 8-25% one particular study reported biochemical recurrence rates of 7% at 2 years and 15% at 5 years. Biochemical recurrence means tumor cells had already left the gland at the time of surgery/radiation and are now multiplying locally, regionally, or distantly.

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Can Active Surveillance Really Reduce The Harms Of Overdiagnosing Prostate Cancer A Reflection Of Real Life Clinical Practice In The Prias Study

Frank-Jan H. Drost1,2, Antti Rannikko3, Riccardo Valdagni4, Tom Pickles5, Yoshiyuki Kakehi6, Sebastiaan Remmers1, Henk G. van der Poel7, Chris H. Bangma1, Monique J. Roobol1 for the PRIAS study group*

1 Department of Radiology & Nuclear Medicine, Erasmus University Medical Center Helsinki University and Helsinki University Hospital , 4Prostate Cancer Program and Radiation Oncology, Fondazione IRCSS Istituto Nazionale dei Tumori , Kagawa University Faculty of Medicine , , The Netherlands

Contributions: Conception and design: FH Drost, MJ Roobol Administrative support: FH Drost Provision of study materials or patients: FH Drost, A Rannikko, R Valdagni, T Pickles, Y Kakehi, HG van der Poel, CH Bangma, MJ Roobol, the PRIAS study group Collection and assembly of data: FH Drost, A Rannikko, R Valdagni, T Pickles, Y Kakehi, HG van der Poel, CH Bangma, MJ Roobol, the PRIAS study group Data analysis and interpretation: FH Drost, S Remmers, MJ Roobol Manuscript writing: All authors Final approval of manuscript: All authors.

*All contributors to the data in this paper are listed in the Table S1.

Correspondence to:

Keywords: Active surveillance prostate-specific antigen screening overdiagnosis overtreatment low-risk prostate cancer limitations

Submitted Dec 11, 2017. Accepted for publication Dec 22, 2017.

doi: 10.21037/tau.2017.12.28

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Finding A Friend Who Understands

Unfortunately, in March 2021, Bobbys three-year biopsy revealed that although his cancer was still small and confined to the prostate, the grade had increased. He would need treatment. He met with MSK radiation oncologists and proton therapy experts to learn about his treatment options but decided to have surgery with Dr. Ehdaie.

Because Dr. Ehdaie is such a strong believer in active surveillance, when he told me I needed treatment I knew I could trust his judgment, Bobby says. To me, it gave him more credibility.

When Bobby was reading about where to go for prostate cancer treatment, he was inspired by a story on MSKs website about Mike Rodgers, a marathon runner and triathlete diagnosed with prostate cancer whod had surgery with Dr. Ehdaie. Bobby reached out to Mike to learn more about his experience. It turned out that the two lived near each other, and Mike invited Bobby to join his Tuesday morning track club. They became good friends.

Before his surgery, Bobby was already an active runner and in good shape. However, once he knew that he would need treatment, he ramped up his workouts. He ran multiple half-marathons and other races to get out of his comfort zone. I called it pre-hab, he says. I knew that surgery would be really hard on my body, so I wanted to be prepared. A month before surgery, at Mikes suggestion, he transitioned from running to focusing on adding muscle and working on his core.

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Active Surveillance in Favorable Intermediate-Risk Prostate Cancer

Another type of prostate issue is chronic prostatitis, or chronic pelvic pain syndrome. This condition causes pain in the lower back and groin area, and may cause urinary retention. Symptoms include leaking and discomfort. In severe cases, a catheter may be required to relieve the symptoms. If the problem is unresponsive to other treatments, your doctor may suggest a surgical procedure. If these do not work, your symptoms could progress and become chronic.

An acute bacterial infection can cause a burning sensation. Inflammation of the prostate can affect the bladder and result in discomfort and other symptoms. This is the most common urinary tract problem in men under 50, and the third most common in men over 65. The symptoms of acute bacterial prostatitis are similar to those of CPPS. Patients may experience a fever or chills as a result of the infection.

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Who Should Consider Active Surveillance

Men with low-risk, early stage prostate cancer can discuss active surveillance with their doctor. As many as 50% of men with prostate cancer have low-risk disease that will not require immediate or aggressive treatment because it is unlikely tospread.

If you are weighing active surveillance against surgery, one study indicated that men with low-risk prostate cancer can safely delay undergoing a radical prostatectomy for up to 12 months after their cancer diagnosis.1

Active surveillance can be valuable for some men because it allows them to avoid the side effects of treatment.

Reasons For Treatment Failure After Going Off As

Urology has long been the specialty that deals with prostate cancer detection, diagnosis, treatment, and follow up. No urologist knowingly or intentionally puts his patients in harms way, but the traditional diagnostic resources are simply inadequate to qualify patients for AS. This means that many doctors are prescribing this balancing act based on educated guesses, and unwittingly leaving some patients with buyers remorse. There is no simple reason for missing a treatment window, but here are some factors that explain the incidence of biochemical recurrence once an AS patient has had aggressive treatment:

  • The prescribing and practice of AS varies widely across urologic communities . Some physicians may include patients with Gleason 3+4 disease, some may have insufficient monitoring tools such as randomized TRUS biopsies that miss progression, etc.
  • Patient compliance may be inconsistent. Early on, patients may agree to annual biopsies but begin to skip them for a number of reasons, fear/anxiety being common.
  • The original diagnosis was mistaken .
  • Lack of genomic information
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    Observation Or Active Surveillance Vs Treatment

    A few large studies have compared observation and surgery for early-stage prostate cancer, but the evidence from these studies has been mixed. Some have found that men who have surgery might live longer, while others have not found a difference in survival.

    So far, a few studies have compared active surveillance to treatments such as surgery or radiation therapy. Men who undergo surgery or radiation do not appear to live longer than those that undergo active surveillance, but their cancer might stay away longer and spread less.

    Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

    Bekelman JE, Rumble RB, Chen RC, Pisansky TM, Finelli A, Feifer A,et al. Clinically Localized Prostate Cancer: ASCO Clinical Practice Guideline Endorsement of an American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology Guideline. J Clin Oncol. 2018 32: 3251-3258.

    Chen RC, Rumble RB, Loblaw DA, Finelli A, Ehdaie B, Cooperberg MR, et al. Active Surveillance for the Management of Localized Prostate Cancer : American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol. 2016 Jun 20 34:2182-90. doi: 10.1200/JCO.2015.65.7759. Epub 2016 Feb 16.

    Last Revised: August 1, 2019

    Who Can Use Active Surveillance

    Locally advanced prostate cancer T3a

    Active surveillance may be an option if your cancer:

    • Is only in your prostate
    • Has a prostate-specific antigen level less than 10 ng/mL
    • Has a Gleason score of 7 or less, which means your cancer is slow-growing. A pathologist will look closely at your tumor biopsy to get your Gleason score.
    • Could be treated with surgery or radiation if it starts to grow

    You must also:

    • Not have any symptoms
    • Feel OK about waiting to see if your cancer grows.
    • Be able to go about your day-to-day life and not worry that your cancer will spread
    • Understand the benefits and risks of your decision to follow active surveillance

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    Observation Or Active Surveillance For Prostate Cancer

    Because prostate cancer often grows very slowly, some men who have it might never need treatment. Instead, their doctors may recommend observation or active surveillance.

    The terms active surveillance and observation mean something slightly different:

    • Active surveillance is often used to mean monitoring the cancer closely. Usually this includes a doctor visit with a prostate-specific antigen blood test about every 6 months and a digital rectal exam at least once a year. Prostate biopsies and imaging tests may be done every 1 to 3 years as well. If your test results change, your doctor would then talk to you about treatment options to try and cure the cancer.
    • Observation is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a mans symptoms to decide if treatment is needed. This treatment is most often meant to control symptoms from the cancer, but not to cure it.

    No matter which term your doctor uses, its very important for you to understand exactly what they mean when they refer to it.

    What Happens During Active Surveillance

    Active surveillance is a form of treatment. Its not the same as receiving no treatment at all. With this method, we put off treatments, such as surgery and radiation therapy, because tests indicate that the tumor is currently not life threatening or is at a low risk of spreading or getting worse.

    Your doctors team up to monitor your tumor for any signs that it may be changing and reevaluate your treatment if the cancer becomes more active. For example, if your Gleason score or prostate-specific antigen level start to rise, we may recommend stopping active surveillance and starting another type of treatment.

    The key to making sure that active surveillance is the appropriate treatment approach for you is determining as certainly as possible that the disease is confined to the prostate and does not have aggressive features. To do this, we may want you to have additional testing.

    Prostate MRI provides the best look at the entire prostate and can identify areas of concern within the gland that might not have been sampled during the initial biopsy procedure. For some men, we may recommend a second prostate biopsy to better determine risk. We may also do genetic studies of your biopsy material to determine whether active surveillance is an appropriate management strategy. By combining several tests, we can assess the risk that your tumor will grow.

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    What Is A Prostate Biopsy

    In men with suspected prostate cancer, prostate biopsy is the standard recommended diagnostic procedure. A prostate biopsy is a procedure in which small samples are removed from a man’s prostate gland to be tested for the presence of cancer. After the biopsy sample has been taken, the prostate tissue is examined by a pathologist to see how far the prostate tissue is from normal. The pathologist will then assign a Gleason score using the Gleason Grading System.

    Prostate Cancer: When To Treat Versus When To Watch

    Localized Prostate Cancer: Active Surveillance – 2021 Prostate Cancer Patient Conference

    Because certain prostate cancers grow very slowly, your doctor might determine that its not likely to present a significant threat to you. This is particularly true if a prostate cancer is localized, meaning it hasnt spread beyond the prostate.

    If thats the case, you and your doctor can discuss getting regularly tested instead of undergoing treatment right away. Doctors call this approach active surveillance. By not rushing into treatment for a cancer that may not cause you any harm, this approach helps many men avoid treatment-related side effects.

    Active surveillance , or active monitoring, means your doctor will monitor you closely, watching to see how the cancer progresses, if at all. This is primarily for cancers that doctors classify as:

    • Very low risk for causing symptoms

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