It is well known that AS will likely end up in treatment.

To some degree we all do a bit of active surveillance as when we get told we have PCa we don't rush out of the doctor's surgery straight into the operating theatre. You almost start to do AS the moment you have that first PSA test.

My understanding was that with AS the idea that you may/will have to treat the PCa at some future date is always part of the plan, and that AS is simply about trying to select an optimum time to carry out any treatment when the stats change enough to merit it. (So that in the meantime you don;t get your QOL messed up by the side-effects)
And as I posted elsewhere this week: it's one thing to know that only 1 in 7 cases of PCa are the nasty ones, so you may not ahve anything to worry about, but it's something else to know that the docs can't tell if you are the unlucky singleton or one of the other six.

Alf

good post alf.

i agree, between my first biopsy and third, which became my PC dx, in a sense I was practicing AS. Lots of monitoring, lots of learning, etc.

Then 3 months after dx, plenty of AS activities went on with me.

i think you made a good point

david in sc

Hey, Terry great to see you over here and by the way, my brother most likely would thank you for talking to him 6-7 yrs. ago about PCa and that with his stats A.S./W.W. would not exactly be a huge risk in his case  (indolent version of PCa).  He has had no psa progression upwards and so far seems very pleased to have great quality of life, while he decides the if and or when and what.

Good luck to anyone on PCa whom believes they are worthy of expertise status and have it all figured out, cases vary like crazy and you and I have seen over 8+ years.  I would not attempt to define this question and answer in totality. Might be interesting to watch the dialogue however, if people don't know you here that well....heads up is my suggestion. Even abstracts can be found in error or contradicted by another abstract....nothing is simplistic.

The difficulty with these kinds of studies, in my view, is that you have to decide what it may mean in your individual case. It's one thing to say that low risk PC can generally be safely watched over time. It's another to establish decisively that yours is a low-risk PC, and that you are safe in doing so. These studies may have meaning for public health policy-makers who deal with large numbers of patients in the aggregate. They have little value for the individual patient, in my opinion.

As a relatively young man with a Gleason 6 T1C cancer, the Bostwick calculator tells me I have an 88 percent probablility that my cancer is organ confined. As we all know, Gleason scores are often revised upward after surgery. Moeover, many people unfortunately don't think very clearly about probabilities, which explains the success of Las Vegas. Even a 99 percent chance that nothing bad will happen means that sometimes bad things will happen. And with cancer, bad things are often really bad. Public health officials may need to consider those kinds of statistics in their cost/benefit analyses, but individual patients need to consider worst case scenarios. Your treatment decision may not be driven by that one percent or five percent or ten percent chance, but you need to consider it carefully.

There are any number of cautionary tales right here in this forum showing how this disease can turn on you in a very nasty way with very little notice. For me, all my accumulated wisdom of five weeks of research (which admittedly is very limited) tells me that I need to err on the side of caution.

Clearly if you have early PCA--e.g gleason 6, low volume of tumor, PSA< 10, and expect to live 10 years or less, AS is the way to go. There is strong evidence for this. No question. Very like it is also if your life expectancy is 15 years, but there isn't direct evidence for that. The fuzzy area is for healthy people who are less than 65. Because of the lack of long term evidence as to what your risk of dying or needed other treatments like HT or radiation as time passes, 10, 15, 20, 25 years after diagnosis, this is a gray zone that people argue about, and choices vary. If you expect to live 25 years, and knew the odds that the PCa would eventually catch up with you, you'd know what to do. Right now, it is a matter of opinion, and all the different opinions in this thread are all valid and reasonable, albeit contradictory. They are just arguments, faith, hunches, repeating the opinions of a trusted doctor, or quoting studies that don't adequately answer the questions.

If there WAS firm evidence, you'd go to the doctor and he or she would say: This is your situation. This is the best treatment. This is why. This is the evidence that the other treatments are not appropriate. You'd go to another doctor and they would say the exactly the same thing. You'd go to the third doctor, same answer. Just like you would if you go to the doctor with high blood pressure. You wouldn't get different answers from different doctors, or go to the internet to help decide what to do.

Postop is correct in that everything concerning pc is probabilities. When considering the probabilities of AS many assume that the alternative, which is treatment, at 100% cure, but it is nowhere that close. If it is really low risk pc stats you still have only a 90- 95% chance of cure and if it really is a G7 you have about a 70%. The immediate death rate for surgery is .5%. These cure rates remain the same if treated immediatiely compared to being treated in three years. The risk of waiting does not decrease you chances of a cure; this may seem strange, but it has been verified time and time again. (Hopkins, UC Davis). In all probability 30% of the men with low stats will need treatment in 3 to 7 years and 50% in 10 to 15 years, but 50% will not, and avoid all the side affects of current treatments with very little added risk. Patients choosing immediate treatment because they expect a 100% cure rate now or expect that their risk of death will radically drop are not basing their decision on factual, verified information. What is certain is that 50% or more of these patients will have permanent side affects from their treatments.
JT

Re : 10 year survival rates for AS/SUR/RAD(external)/SEEDS
for diagnosed localized prostate cancer in the 1990's.

Whether you want to believe the study reprized in the CROH
(Consumer's Report on Health)/Oct-10 issue, at least they quote
statistics on 10 year survival rate for diagnosed localized
cancer (2010 study of 6849 Swedish men, so, treatment done in
the 1990's)--that include those incorrectly diagnosed as
localized (maybe the current 2010 diagnosis is more accurate??)
The results are quoted for 4 cases--AS (Active Surveillance),
SUR (mostly open, since it's in the 1990's), RAD (external beam),
and SEED (radiactive)

the results (approximate) for 10 year survival rate (from prostate cancer)
low risk intermediate risk
AS 3% 5%
SUR <1% 3%
RAD 2% 4%
SEED not available; potentially similar to RAD

Assuming that the average age at diagnosis is 65 (my guess),
that would imply a 5-20% increase in death rate, since a
65 year old person have a 20-40% chance of dying in 10 years
anyway from other sources. Thus, AS would increase the death rate by
2% compared to the most "optimal"?? option--SUR--so a 1/20-1/10 increase in
death rate, while being able to avoid all the side effects, at least
for a while.

My guess is the death rates for SUR are those mis-diagnosed
as low/intermediate risk, but with actually metastatized cancer.
RAD (at least around 2000), may not be as effective, but are
likely to be better in 2010.
The additional rate from AS vs. SUR are those localized cancer
that spread before one catches the spread and treatment.

So, if this interpretation is correct, is a 7+-2% increase
in death rate worth avoiding the side effects for years (1/2
to 2/3 of low risk AS do not need further treatment within
5 years). A difficult choice that one must make for localized
Prostate Cancer.

In my case, Gleason 4+3=7 T3b, there is no choice but
treatment !!!

JohnK,
Most of these studies AS means never treated and no one belives this should be the case. The real defination of AS is getting treated only when it shows signs of progression, which usually occurrs in under 3 years.
If we use this defination then the cure rates are the same.
JT

First of all, let me say that I entirely agree with Red Nighthawk when he refers to the polite and civilised way this discussion (and others I have read on this site) are conducted. But having said that, I also have to say, that like so many threads on Forums like this my original point was not really addressed as the discussion meandered along.

A statement was made by Tony: “It is well known that AS will likely end up in treatment.” I think that this statement may not be correct and may be based more on personal perceptions than the reality of whatever data is available. In saying that I am not criticizing Tony in any way: we all interpret data through the spectrum of our personal experiences and outlooks – I’ve even been known to interpret data supporting Active Surveillance in that way, believe it or not!

Perhaps I can just start by referring to English Alf’s post. Although there is no agreed definition of AS, what he sets outas “My understanding was that with AS the idea that you may/will have to treat the PCa at some future date is always part of the plan, and that AS is simply about trying to select an optimum time to carry out any treatment when the stats change enough to merit it. fits the understood definition of Watchful Waiting more than Active Surveillance. Men who choose AS often do so on the basis that their diagnosis may be of one of the variants in the disease that will never present a threat to their life and therefore they may never need therapy. This may seem a fine distinction and my personal view is that it is too fine, but…..it is held by many.

Tony seems to be saying that the aims of the AS men – to avoid unnecessary treatment – are unlikely to be achieved and he says this is ‘well known’. But….as JohnT says with reference to the Klotz study, the majority of men enrolled in the study are still there at a median of seven years after the study started. Now that is a relatively short time, but it is also worth noting in passing that at least two other AS studies are showing a similar pattern and, what is more about 25% of the men in the study have had negative second (and some third) biopsy procedures. That doesn’t necessarily mean that they no longer have prostate cancer of course, given the hit and miss nature of biopsy, but there is no evidence of progress and it is also worth bearing in mind that if their second or third biopsy had been their first, they would not have been diagnosed with prostate cancer and would not be on a formal AS program.

Which brings me to the other point made by JohnT The stat for me that is hard to get over is that 50% of all men will have some PC after 50 and 16% will be diagnosed at some time; yet only 4 % ever die from it. This indicates that there are a bunch of 50 year olds that will never even realize they have pc in their lifetime.

The first oncologist I consulted said that in his opinion and experience and in the light of available studies, the percentage of men who had cells in their glands which would be identified as ‘cancer’ using the then current definitions was roughly the same percentage as their age – in other words about 60% of men aged 60: 70% of men aged 70 and so on. If he is correct and if we don’t change the definition of ‘prostate cancer’ too much again (bearing in mind the significant changes announced earlier this year) then as John T says there are many, many men who are unconsciously practising WW (rather than AS) and for the majority of these men there is no prospect of the disease they are carrying becoming life-threatening, so they are unlikely to end up in treatment.

All in all these are some of the reasons that I think Tony was not correct in what he said, but I’m open to be persuaded by presentation of any reasonable evidence to the contrary.

Just to touch on a couple of other good points from the thread.

Jazzman 1 said The difficulty with these kinds of studies, in my view, is that you have to decide what it may mean in your individual case. It's one thing to say that low risk PC can generally be safely watched over time. It's another to establish decisively that yours is a low-risk PC, and that you are safe in doing so.

And Post op said If there WAS firm evidence, you'd go to the doctor and he or she would say: This is your situation. This is the best treatment. This is why. This is the evidence that the other treatments are not appropriate. You'd go to another doctor and they would say the exactly the same thing. You'd go to the third doctor, same answer. Just like you would if you go to the doctor with high blood pressure. You wouldn't get different answers from different doctors, or go to the internet to help decide what to do.


This uncertainty is certainly a difficult thing to deal with, but is there any more certainty in ANY aspects of our lives? Can anyone say, in full confidence, that they will not die of any of the seven causes of death that outrank prostate cancer and that therefore prostate cancer will get them if they don’t do something. From my point of view it is important to know that statistically there is a 97% chance of my dying of prostate cancer and a 3% chance of my dying of the disease. Just how this population based statistic applies to me can only be guesswork, but there are guidelines that clearly separate the very dangerous from the very indolent – at least in my understanding.