Study: Surveillance Is for Middle-Risk Prostate Cancer - & more evidence of the success of LDR BT

This has just come out in the February 19 of JAMA Oncology:

"Monitoring prostate cancer (PC) by active surveillance (AS), with the expectation to initiate treatment if the cancer progresses, is a preferred initial option for men with low-risk PC and a life expectancy of at least 10 years. According to the results of a new study conducted at Brigham and Women's Hospital (BWH), there is evidence to also support AS as an initial approach for men with favorable intermediate-risk of PC (men with no evidence of the cancer spreading beyond the prostate, a Gleason score of 3+4 or less and PSA, prostate-specific antigen, under 20). These findings are published online by JAMA Oncology.

"We found that men with favorable intermediate-risk prostate cancer did not have significantly increased risks of death compared to men with low-risk prostate cancer," said Ann Caroline Raldow, MD, first author of the study and resident physician at BWH and the Harvard Radiation Oncology Program. "The clinical significance of our findings is that men with favorable intermediate-risk prostate cancer may also be able to avoid, or at least defer the side effects of, prostate cancer treatment, and enter an active surveillance program as an initial approach."

Researchers estimated and compared the risk of PC-specific mortality (PCSM) and all-cause mortality (ACM) following brachytherapy among men with low-risk and favorable intermediate-risk PC in a prospective cohort study of 5,580 men (median age 68 years) at the Prostate Cancer Foundation of Chicago between 1997 and 2013. Men with favorable intermediate-risk PC, who had no more than half of all prostate biopsies containing PC, were included in the study and were treated with prostate brachytherapy alone.

The researchers found that men with favorable intermediate-risk did not have significantly increased risk of PCSM and ACM when compared to men with low-risk PC after a median follow up of 7.69 years. Additionally, the absolute estimates of PCSM were less than one percent in men with low-risk and favorable intermediate-risk PC, suggesting that men with favorable intermediate-risk PC may also be candidates for active surveillance.

To date, no direct comparison had been made between favorable intermediate-risk and low-risk prostate cancer with respect to PCSM or ACM following brachytherapy.

"While awaiting the results of ProtecT, a randomized trial comparing active surveillance with treatment, our findings provide evidence to support a discussion of AS as an initial approach to men with favorable intermediate-risk PC," said Anthony Victor D'Amico, MD, PhD, senior author of the study and chief, BWH Genitourinary Radiation Oncology."

Also - "One of the most important findings is that favorable intermediate-risk cancers can be very well controlled with brachytherapy. Additionally, the absolute estimates of PC-specific mortality (PCSM) were less than one percent in men with low-risk and favorable intermediate-risk PC."

So something more to add to the quiver of AS and LDR BT.

Phenom said...
And are they saying that less than 1% of low and favorable intermediate-risk patients would die of prostate cancer no matter whether they were treated or not?

I believe this is a validation of previously presented data which is now several years old now.

There is a very small percentage of cases which initially presents as low risk which end up being very aggressive, and is impervious to treatment.

Post Edited (JackH) : 2/19/2015 4:32:33 PM (GMT-7)

Yoop, yeah man thanks for all your hard work. I think I am going to try that active surveillance. In the word of the coolest beagle ever.... Snoopy... Bah ha ha ha ha

"Monitoring prostate cancer (PC) by active surveillance (AS), with the expectation to initiate treatment if the cancer progresses, is a preferred initial option for men with low-risk PC and a life expectancy of at least 10 years. According to the results of a new study conducted at Brigham and Women's Hospital (BWH), there is evidence to also support AS as an initial approach for men with favorable intermediate-risk of PC (men with no evidence of the cancer spreading beyond the prostate, a Gleason score of 3+4 or less and PSA, prostate-specific antigen, under 20). These findings are published online by JAMA Oncology."

So, what this says to me, is that only GLeason equal,to or greater than 7 (4+3) that appears to be contained, should be considered for surgery, since most DRs would NOT recommend surgery to ANY patient with less than 10 years life expectancy.

The big question for me would be, for those men with low intermediate risk, does initially choosing AS ultimately raise their risk of needing treatment at a more advanced stage later, When neither Brachy nor surgery would offer a cure, thereby putting them at risk for lesser quality of life with radiation AND HT.

I maybe be way off base here, as I'm not that well versed in treatment of advanced cases. Just thinking out loud and playing devils advocate.

Both Brachy and surgery offer the same 1% PCSM rate as mentioned for AS in the study. So does AS now increase the chance of requiring more difficult treatment later.

There is no question in my mind that Brachy offers the same chance of cure to these men as RP. I'm still not convinced that AS is a riskless treatment.

Yoop, it's great that you bring this stuff to the forefront for discussion. Thank you.

I do think this could be pushing the envelope with the definitions here. Lots of shadings of gray, and hard to say when things actually move from white to black from a diagnostic point of view. If I was a 3+4 I might have to swallow hard before considering AS.

And you're right that AS is not a risk-free treatment--there are no free lunches in this cr@ppy game we all have to play. But I do think given the risk/reward ratio it can make sense for some people. And if I had to guess, it makes sense for more people than actually embark on that path.

What would help address these questions of whether there is a monster hiding under the bed or not for all these new guys is a comparative study of outcomes of these two groups:

Group A- men with favorable-risk PC who went for immediate aggressive treatment, and

Group B- men with similar favorable-risk PC who went into an AS program, but later progressed past the AS trigger point for curative treatment and received deferred treatment.

Hmmm....?

Post Edited (JackH) : 2/20/2015 5:27:13 AM (GMT-7)

The OP (original poster’s) article actually supports the points Drs Thompson and Vickers made (in the posting immediately above), but I’m not so sure they are necessarily such a strong endorsement of BT as the thread title suggests.   I’ll explain:   The paper from Dr D’Amico as senior author (globally recognized PC expert) looked at >5,000 patients with low-risk or favorable intermediate-risk PC treated with first-line BT at one institution, the popular Prostate Cancer Foundation of Chicago between 1997 and 2013.   The men had these VERY common characteristics:    * GS of 3+3 or 3+4    * a percentage of positive biopsy cores of <50%    * at most one NCCN determiniant of intermediate-risk cancer (GS=7, PSA 10-20ng/mL, and T2b or T2c)   The results suggest that men with favorable intermediate-risk PC are actually good candidates for AS (as the OP properly portrayed).   Is that, however, an endorsement for BT?     The paper says that BT provided effective PC management, but the main point was that these men didn’t necessarily need this type of immediate invasive, aggressive management.   Some may have needed deferred treatment later (about 30% of AS patients do), but not immediately.     This resonates closely with the message Drs Thompson & Vickers said 20+ months ago…” if you have a choice of a dollar today or a dollar 10 years from now, take the dollar today. But if you have a choice of a curative treatment for prostate cancer today or a curative treatment for prostate cancer 10 years from now, choose it 10 years from now”       Post Edited (NKinney) : 2/20/2015 9:18:18 AM (GMT-7)

PDA, this study examined outcomes of the set of men on BT in comparison to similar cases of men who went on AS.

This study is based on a large, consistent series of men all treated at a single institution over 15 years, and the analysis appears to have been conducted with a great deal of care and rigor by renowned authors, including D'Amico but also Dr Brian Moran from the Chicago BT center. 

Full report:  http://oncology.jamanetwork.com/article.aspx?articleid=2118571

Added as an edit:  Look, don't get me wrong, I'm not bashing BT.  I'm bashing overtreatment of favorable-risk men.  BT+IMRT plus HT seems like an excellent option for guys outside of the favorable-risk category, for example.  PC is really a spectrum of diseases, all with the same name...but we've got to stop treating them so similarly.

 

Post Edited (NKinney) : 2/20/2015 10:07:12 AM (GMT-7)

All the men in the study were treated with BT at the Prostate Cancer Foundation of Chicago between 1997 and 2013.  Yes.  That is correct.  I already said this, above.  This was Moran's contribution.

 

The D'Amico (lead author) report I posted used those results and then compared their outcomes with outcomes of men in another study (ProtecT) with similar case characteristics who DID NOT pursue immediate treatment.

 

 

 

 

You're thinking there is a conspiracy theory in the conclusions...?!?!

 

Post Edited (NKinney) : 2/20/2015 10:07:30 AM (GMT-7)

Nkenny,

I don't have an agenda and I don't see conspiracy. I am simply pointing out that the study -- which should be very reassuring for favorable intermediate-risk men seeking brachytherapy -- does not provide any direct evidence for active surveillance. None of the participants were on AS.

It could easily be that the authors, having access to some of the preliminary ProtecT data, are giving us hints. (ProtecT is due out next year. Here is what they expect it to address (from the Lancet))

Without getting into the conspiracy theory ....

If I am a newbie and read Yooper's original post and the subsequent posts I conclude that:
1. If you are a G6, do AS unless you have an overwhelming reason to do brachytherapy,
2. If you are a low grade G7 (3-4), you may want to discuss (??) AS; however, should you choose brachytherapy your results will be as good as a G6 who (mistakenly? (Refer to item 1.)) chose to be treated with brachytherapy.

This seems to be the same as what TA said 20 months ago. What am I missing? The ProtecT study?

RCS, read it again with this guidance: if you are in the 3+3 or 3+4 favorable risk category, your outcomes with BT will be similar to men who pursue AS. This speaks to the outcomes only...there are other pluses and minuses to choosing either route. The earlier posting extens this notion beyond BT to the other forms of immediate aggressive treatments...the outcomes are all good, not great.

Done.  Several years ago. 

A UC-Davis study compared pathological outcomes of men undergoing RP after a period of AS (skewed distribution; median 18-months) with those of a similar risk group undergoing immediate surgery, and concluded with these important points:

• rates of Gleason upgrading did not statistically significantly differ
• rates of pathological category pT3 did not statistically significantly differ
• rates of positive surgical margins did not statistically significantly differ
• rates of non-organ confined disease did not statistically significantly differ

Results of this study did not include other modes of aggressive, immediate treatment (RP only), but other studys consistently show outcomes of all aggressive treatment modes to be similar...good, but not great.

Study name:  "Surgical management after active surveillance for low-risk prostate cancer: Pathological outcomes compared with men undergoing immediate treatment"

Study link:  http://www.urotoday.com/index.php?option=com_content&task=view_ua&id=2231732