Delayed Treatment After Active Survelience

A study posted on the New Prostate Cancer Info Link on the UCSF program on AS for intermediate and low risk PC confirms the same results that Hopkins and other institutions have found that delayed therapy after 3 years of Active Surveilence produces the same results as immediate treatment.

113/376 low-risk patients (30 percent) and 32/90 of the intermediate-risk patients (35 percent) had opted to initiate treatment after some time on active surveillance.

Of the patients who had opted to initiate treatment by surgery (which was the most common form of therapy)

• None were found to have lymph node positive disease.
• None had had a post-surgical rise in their PSA level within 3 years of surgery.

The data has been pretty consistant in that about 1/3 of the patients on AS will at some point opt for treatment within three years (this is when most of the progressions are discovered) and there is no or very little added risk for the group of carefully selected patients who delay treatment. This is true for not only low risk patients, but also intermediate risk patients. I'm not recommending AS for intermediate risk patients unless they are older, but the data is becoming overwhelming that patients on a carefully monitored AS program when treated for any sign of progression fair just as well as those who were treated immediately.

I know that many will find this hard to believe and think that AS is way to risky to even contemplate, but the data is consistant. Delayed treatment for the ones that progress is similar to immediate treatment, and 50% to 70% of those on AS show no sign of progression in up to 7 years, which are as far as current studies go.

JohnT

John,

I am wondering if this would also apply to adjuvant vs salvage radiation. I have seen some numbers that imply that adjuvant has a better odds of no BCR vs. salvage.

I consider myself in an AS mode, waiting for an uptick in PSA before initiating phase II. Frankly with a G9, it may be a futile attempt anyway, so I am playing the QOL game as well.

This study just kind of caught my eye.

Here is the link to the article John posted about:

prostatecancerinfolink.net/2010/12/11/11216/

I posted two pennies worth myself. I think it's reasonable to not treat G7 prostate cancer if the patients health is poor and life expectancy is short. But as I posted in the thread at the InfoLink, I am glad I am not the test subject. It certainly is OK to not rush into any treatment and allow time for the patient to investigate all of his options.

But I am getting concerned that doctors may in fact be pushing the envelope in trying to decipher who is a good candidate. Balancing "QoL" with a gray area seems like a risk I would never partake in. Increasing the risks with AS has to have at least some negative affect on QoL.

Tony

John, thanks for posting this.  This should be encouraging for those involved in or considering AS. This obviously confirms the existing research on low risk patients but this is the first data I have seen on intermediate risk patients.  As an intermediate risk patient myself (and a young 62 and healthy) I did not choose AS but it is VERY interesting to see data that indicates what might have happened if I had done so.  It will be interesting to see if other studies bear this out.

Questions, AS is not "doing nothing"...in fact it is much different than that.  I understand that you would not meet the eligibility requirements anyway with a postive DRE and an admitted "get it out" attitude but we are all different.  I suggest you go back and read some of the other posts on HW on this subject and I think you may understand some of the thinking of men who have chosen that path.  Again, that doesn't mean it is for you but hopefully you will gain some perspective why it is a legitimate approach...

Tudpock (Jim)

Tud,
I was on AS unintentionally for at least 10 years and most likely 12 years with a G4+3. It may have started as a G6, but who knows. It looks like even after a delay of 10 years, treatment is having the same results as if I were treated 10 years ago, but 10 years ago radiation and robotics were not where they are today, and I would have most certaintly suffered some side affects that would have had an impact on my QOL for that 10 year period. The anxiety I felt during those 10 years with quarterly checkups is exactly the same as I have today after treatment whenever I get my psa tested. I asked my onco what would happen if I did nothing. He said I would most likely be symptom free for 10 more years.
I wouldn't recommend AS for anyone who has intermediate risk PC unless they are in their 70's or in poor health, but the data is pretty interesting. I think the most important thing to take away is that PC is really not just one type of cancer, but a spectrum that goes from harmless to agressive and you have to fit the treatment to what you have and not treat all PC the same. For agressive, high risk PC I don't think that most patients are agressive enough in their primary treatment opting for a mono treatment rather than a combination and too agressive in their treatment of low risk PC.
JT

Ziggy9 said...
I didn't do AS instead I was treated by TFT a far less invasive clinical study. Which many here thought I was crazy to risk. For me a less invasive treatment in an age of massive over treatment was a no brainer. That said as time has passed by and more information has come out I may have well chosen AS now with what I know. But the decision for me wasn't AS vs Radical treatments but what has been going on 3 years a very successful treatment whose only effect is maybe a 60% loss of ejaculate.

As you point out, your treatment was part of a clinical study, which involves the risks of unproven over standardized treatments. Hindsight tends to be 20/20 if the experiment worked, but if not? Treatment is a very individual decision. All the best on your continued success!

Post Edited (TimG) : 12/14/2010 1:13:17 PM (GMT-7)

An, I really had not thought about this study in the light you presented but I think you made a very good point.  That should definitely be encouraging to you and Paul.  Best wishes and prayers for continued success.

Tudpock (Jim)

Ziggy,

This new therapy (TFT) sounds very promising, especially with your good results.  Do you know if it is expected to be made more widely available, or is it still in the study phase? 

Tim

Jazz, that is one of the risks of doing AS that not even your doctor could answer, its not uncommon to have an upgraded Gleason post surgery.

Ziggy9 said...
But it's true that by not having radiation leaves it as a secondary treatment if necessary but most gloss over the fact it only has a 30% success rate.

As a relative newbie, do I assume that you are saying that RADIATION only has a 30% Success rate.. A very good reason for NOT considering it as a first step, if it means that surgery is pretty much OUT after Radiation, and Radiation only starts the problems of Incontinence and ED, which I understand, creep up over the next few years..

[Quote]Many here who have had surgery, find themselves soon after with systemic PCa, or lifelong effects.
Could I suggest that there should be a special qualification to that comment.. Most Folk hanging out here have a problem. By far the greater number of those who have surgery, never come back here.. The general statistics suggest that 95% can be guaranteed a normal life after an RP. That may be questioned by the percentage, for whom Incontinence and ED are an issue, but they still know that there is only a 5% chance of Systemic PCa.


[quote]For those with low risk PCa, many rather just worry about possiblities than have to wonder about incontinence that worse case scenario may never get better and likely long lasting ED and it's effect on relationships. All of a sudden 15 years of AS looks like a pretty good option IMHO over those.
Yes - that is the whole problem.. How does one define QOL... Sleeping well in the belief that I have a 5% chance of failure, or stressing the heart with the fear that the PSA will JUMP just after my next PSA test and that it might have escaped, by the time I have another.

Still - JohnT's observations are reassuring that given the RIGHT circumstances, AS can be a positive thing, if the patient has a positive attitude..

It's normal for many here to justify their treatment by condemning others or especially AS. Those most vocal about it for some reason are many who have not been at this site long and soon are mass posting after treatment. I do hope your side effects get better but you shouldn't condemn those who aren't in a rush to experience and can live with PCa.
I suppose that many could be hurt by being criticised for their treatment decision (or lack of it ), by those who are convinced that statistically, the risk is NOT there in the first place, and that AS is the way to go. It's a two way street !

I would have thought that each is likely trying to justify their choice, and that NEITHER is critical of the other... Just trying to ensure that a third-part, sitting back and observing, is aware of ALL the issues..

Like folk talking about Radiation, and how minimal invasive it is and how few the side effects are, but omit to mention that once irradiated, the goose is cooked and it's pretty much down hill from there until after three years, you are pretty much where the RP chap starts with lots of hope.. ( or that's at least as I have been told by Professors of Radiation - DON'T have radiation ! except ...... )

I would have been OK with AS, but ED would have been an absolute certainty, after castration by the bride, if I did not get cut and, after the Onc. told us of the prognosis.. Now, ED is a 50/50 thing, and I still have the family jewels !
Where there are Jewels - there's hope !

NO - I would hate to think that ANYONE reads discussion as criticism of personal choice.
Many of us Newbies might be just trying to convince ourselves that WE made the best choice for our situation.. Just as the Oldbies are convinced that they are right, whilst they await that NEXT PSA...

.
.

Actually, I think Ziggy might have meant that the success rate of radiation following surgery is not that high. We were told that by both our urologist and the radiation oncologist during our consultations. Neither doctor (one of whom is a surgeon) pushed us in any direction, but were trying to point out that the 'radiation as a backup for failed surgery' wasn't the best reason to choose surgery. I also read this in a book I picked up.

Success rates for radiation as a first choice therapy (for those carefully chosen candidates) are certainly better than 30%. And the 'goose is cooked....pretty much downhill from there' comment is, in my opinion, unfounded.

As to the original question regarding AS, I KNOW my husband would have chosen it if he had been able.

Juliet

TimG said...
Ziggy,


This new therapy (TFT) sounds very promising, especially with your good results. Do you know if it is expected to be made more widely available, or is it still in the study phase?



Tim

I expect it to be more widely available. I'll ask my doctor next time I see him. It's received more and more press as time goes by. There is of course much push back from those paying off DaVinci machines. The current stage of PCa is a cash cow where many will resist less costly and invasive treatments for sake of the bottom line. In fact my insurance paid for the procedure and only balked at the 3D saturation mapping biopsy until its purpose relevant to TFT was explained to them on appeal and then approved. The targeted cryosurgery was never a problem nor would I believe it also being done by laser now.

Buidoi,
You seem to have picked up some misconceptions about radiation. First of all the cure rates are similar to surgery and in many cases better among all risk catagories and the side affects are generally better, absolutely in the short term and most likely in the long term.
The prime reason surgery fails for non systemic cases are that every surgery leaves a small amount of prostate tissue around the nerves and in the APEX, or there is a small margin of PC cells in the prostate bed. This can be cured by salvage radiation, but would have been easily taken care of with radiation as a primary treatment.
There are also many alternatives to failed radiation for localized PC, seeding, HDR Brachytherapy, cryosurgery that all have the exact same cure rates as salvage radiation after surgery.
The incidence of incontinence is very rare with radiation as opposed to surgery and ED rates are slightly better at the 3 years mark and are more responsive to medications than ED from surgery. There is a slightly higher risk of bowel issues from radiation. With seeding, incontinence and bowel issues are rare, because the radiation only effects 1mm from any seed.
JohnT