Posted 3/4/2016 7:47 PM (GMT 0)
HFTB, I just threw out 4" of the 6" of journal articles and other information I gathered, and read, when deciding whether to treat and if so, with what. The remaining 2" pertains to the treatment I chose, CK. I picked CK because, after speaking with 11 specialists, including Alan Katz and some other heavy hitter ROs, they all recommended I treat, not necessarily immediately, but sooner rather than later; because my research indicated surgery had far worse ED outcomes statistically speaking than CK (or HDR); and because the 9 year cure rates based on Katz's data for low risk PCa is over 90%.
Based on your profile, I'm more than a little surprised the docs aren't encouraging AS. You may want to dig a little deeper into that option before deciding on a treatment option. And please ask all your docs whether AS is an option for you. I cold-called many of the RO gurus and found them all incredibly helpful and supportive; can't tell you how much their consults meant to me.
I'm going to post below the email I recently sent my twin brother, who has a profile very similar to mine, about AS, which is his preference, as this may shorten your research time:
"If you read the underlying Sunnybrook study [here's the link to Allen's synopsis of it: http://prostatecancerinfolink.net/2015/04/21/active-surveillance-today-a-summary-of-the-sunnybrook-experience-and-related-factors/], it included these comments:
"about 25% of men initially diagnosed with Gleason 6 on biopsy have occult [ie, hidden] higher grade cancer, and these appear to be responsible for most of the prostate cancer deaths reported in series of conservative management. These case reports are a challenge to the view that Gleason pattern 3 does not behave like a malignancy. Importantly, concerns about the risks exemplified by these cases should be balanced against the extensive clinical evidence supporting the absence of metastatic potential in the vast majority of pure Gleason pattern 3 cancers.
Many studies have demonstrated that men with high-volume Gleason pattern 3 have a higher risk of harbouring higher grade cancer. A threshold of more than 8 mm of total cancer on systematic biopsy has recently been described [35]. [Scott, you have 10mm and 9mm cores, which is over 50% cancer volume.] The management of patients found to have higher volume Gleason 6 is to exclude the presence of higher grade cancer as rigorously as possible (based on MRI, targeted/template biopsies and biomarkers). A finding of higher grade cancer in most cases warrants intervention; the remainder are unlikely to require treatment."
Surprisingly, the Sunnybrook article doesn't discuss who's eligible for AS.
For men with low testosterone, they may be at higher risk of having the aggressive disease per a recent study:
"These results suggest low levels of testosterone are associated with more aggressive prostate cancer. This contradicts long-held beliefs that high testosterone is risky for prostate cancer, and low testosterone is protective," said Dr. San Francisco. The results of this study provide valuable information to clinicians and their patients concerning risk factors for prostate cancer progression in men undergoing active surveillance. "In borderline cases, the presence of low values of free testosterone may help determine whether it is more prudent to initiate treatment rather than continue observation," said Dr. San Francisco.
https://www.sciencedaily.com/releases/2014/05/140505094213.htm
Johns Hopkins has been the leader in AS protocol since the start of their study in 1995.
You and I are "low risk" per the Hopkins standards, but wouldn't be among those recommended for AS because we are younger than 65 and have bilateral disease (the audio link below says Hopkins no longer uses # of positive cores but whether the PCa is bilateral):
Low-risk: Characteristics of a man considered to be at low risk for progression of his prostate tumor would include a Gleason score of less than 7, a PSA measurement of less than 10, and stage T1c or T2a disease. Surveillance would be the preferred option for men with low risk prostate cancer that have less than a 10 year life expectancy; and should be considered for men over age 65 years.
http://www.urology.jhu.edu/prostate/active_surveillance_selection.php
Here's a relatively brief audiogram (12 minutes) about the changed criteria for who qualifies for AS:
http://urology.jhu.edu/audio1/carter0902.mp3
Yes, this is all rather confusing. The ASCO guidelines seemingly suggest AS for folks under 55.
NCCN is another highly reputable organization making AS recommendations:
"In 2010, the NCCN Guidelines established a new “very low risk” category that incorporated the strictest Epstein criteria from all definitions for clinically insignificant prostate cancer and recommended active surveillance as the sole initial treatment for men who meet these criteria and have a life expectancy of more than 20 years. Men with low risk prostate cancer and a life expectancy of less than 10 years should also be recommended for active surveillance.
In the updated 2011 NCCN Guidelines, active surveillance monitoring was made more rigorous for men in the very low risk category. For those with a life expectancy of less than 20 years, PSA must be measured at least every 6 months, prostate exam must be performed at least every 12 months, and repeat prostate biopsies should be considered as often as every 12 months.
Dr. Mohler noted that there are several conundrums related to active surveillance that complicate the issue further, including overtreatment rates, clinical risks associated with prostate biopsies, and differing criteria for active surveillance and disease progression in large clinical series, all of which need to be taken into consideration when making treatment decisions.
“Ultimately, this decision must be based on careful individualized weighting of a number of factors and is an option that needs to be thoroughly discussed with the patient and all of his physicians. Clearly, more clinical research is necessary to better inform decision-making,” said Dr. Mohler.
http://www.nccn.org/about/news/newsinfo.aspx?Newsid=274
Renowned urologist Dr. Peter Carroll at UCSF discussing AS criteria in a 2008 interview:
Dr. Peter Carroll:
First, let me state who are the best candidates for active surveillance. The best candidates for active surveillance are those men with low-grade prostate cancer, what we call no-pattern four or five score to their biopsy. They have cancers which either can't be felt or seen or those that can be felt or seen but confined totally to the prostate, what we call T1 or T2a disease, less than 1/3 of the biopsy is positive, and most of these men have had 12 or more biopsies done, so less than 1/3 of the biopsy is positive and less than 50 percent of any single core involved. That tends to define a group of people with very limited disease who are good candidates for active surveillance.
I tell patients active surveillance is not so much about whether you treat or you don't treat. It's about the timing of treatment. Does every man need to be treated right now versus actually following them for awhile. Some men may not need any treatment, but for those that do need treatment it does not look as best we can tell that they compromise their ability to be effectively treated.
Now, there's always some risk with active surveillance. We think that risk is quite small, but if a patient is not willing to take on any risk that the tumor could grow in that interval, then perhaps they should consider immediate treatment.
https://www.ucsfhealth.org/education/interview_carroll_active_surveillance_for_prostate_cancer/
Unfortunately, as of 2016, criteria for AS still haven't been standardized:
http://onlinelibrary.wiley.com/doi/10.1111/iju.13016/full
A recent study showing death rates for treating and not treating low risk disease are the same for a median of 10 years:
"The present study shows that in low-risk patients, following diagnosis, the risk of progression to a dangerous phenotype is low for a median of 10 years. Summing up the message from their study, the authors state, “Our data suggest that, for men with favorable-risk prostate cancer, the paradigm of immediate intervention must be replaced by one of immediate contemplation and a thoughtful assessment of prognostic risk, life expectancy, and the relative risks and benefits of available management options considered in the context of personal preferences.” - See more at: http://www.targetedonc.com/news/psa-screening-leads-to-overtreatment-of-low-risk-prostate-cancer-says-long-term-study#sthash.2Jq3whMy.dpuf"
I wish I knew how to hyperlink here, but I fail miserably each time I try...... Please copy and paste any link you'd like to read.