My current Active Surveillance plan - sound right?

After being diagnosed in August with 2/14 cores of G6, I decided to give MSKCC's AS program a shot.

The current plan is to have a PSA test in February 2018 and then a confirmatory biopsy within three months of that. The doc stated that that these are the only tests scheduled (if there's no dramatic uptick in PSA) for the immediate future.

When I questioned about Decipher or Prolaris testing, he stated that I currently "just don't have enough cancer for those tests to provide accurate or meaningful assessments."

I was wondering if anyone else had heard of or was told this?

Thanks in advance for any replies.

I have not but did learn, from my doc, that the initial stage of the sample highly predicts the outcome of the tests. I don't see an MRI in your plan, which looks to be common elsewhere? Sounds like you are in good hands. Be well. Denis

The genetic test is interesting, but not likely to change your treatment plan. Looks like you've got a great plan there.

Andrew

As the others have said, that sounds like a good protocol.

As for genomics tests, Johns Hopkins used the OncotypeDX assay with me. That, along with two you mentioned, all produced good results in studies. You really do have minimal amounts of cancer, and it may be below the sample size needed for those tests.

Together with my PSA jump from 5 to 7.5 this year, my mpmri PIRADS 5 lesion is one of the reasons leading me to look for some kind of treatment right now. But mpmri suspicious level is not mentioned in most lists of conditions for AS elegibility, maybe it is a too recent concept only used for followups. Also, mskcc now uses unilateral positive cores in biopsy (another feature I do not have) to qualify for very low risk patients. Low risk patients (next category) are advised to be on AS preferably if they have a life expectancy shorter that 10 years (I hope I am not in this group, either). More open conditions are used in other centers (<T3 stage, <G4+3 or even <G8 and <PSA 15 are the most relaxed ones).

In my own experience, both Prolaris and Onctotype DX tests are of limited benefits based on the samples tested.

I was on AS for about 5 years, had a Prolaris test which indicated very low risk, 2% 10 yrs.
Oncoytype DX showed Low Risk, 72% of favorable pathology.

However, on the fourth Bx in May 2017, 1 G9 (4+5), 1G8 (3+5), one G7 (3+4) and couple of G6.

What gave me a hint of progression was the PSA test, from Sep 2015 to Feb of 2016 my PSA went from 3.8 to 4.74, almost a one point jump. Bx in May of 2016 yielded only G6s. My PSA kept rising and in May of 2017 reached 5.2. Fourth Bx in May of 2017 was a shocker. All three previous Bxs showed only G6s.

So for me, PSA is one of the most important tests while on AS, just watch the trend.

jmadrid said...
Together with my PSA jump from 5 to 7.5 this year, my mpmri PIRADS 5 lesion is one of the reasons leading me to look for some kind of treatment right now. But mpmri suspicious level is not mentioned in most lists of conditions for AS elegibility, maybe it is a too recent concept only used for followups. Also, mskcc now uses unilateral positive cores in biopsy (another feature I do not have) to qualify for very low risk patients. Low risk patients (next category) are advised to be on AS preferably if they have a life expectancy shorter that 10 years (I hope I am not in this group, either). More open conditions are used in other centers (<T3 stage, <G4+3 or even <G8 and <PSA 15 are the most relaxed ones).

I think you misunderstand all of that. PIRADS 5 on mpMRI is never used as an independent risk factor for AS by anyone in the US. It is not a diagnosis for prostate cancer of any kind. It only highlights areas that are suspicious for follow-up biopsy. It only increases the risk that high grade cancer will be found on a biopsy. It is only the biopsy results, not the mpMRI results, that are used to qualify a man for AS. It is not because it's too recent - in fact, it's been used at places like MSK for quite some time.

The NCCN recommendations, which MSK follows (they wrote them), do not state what you think they do. For low risk men with a life expectancy of < 10 years, it is not active surveillance that is recommended, it is observation (watchful waiting) - a very different thing. That is because something else is more likely to kill the patient before prostate cancer does. Unlike AS, watchful waiting only involves palliative treatment, not curative treatment, if the cancer becomes symptomatic.

In fact, NCCN recommends AS as the preferred option for low risk men with life expectancy >10 years. NCCN low risk means stage T1c/T2a and GS=6 and PSA<10. Moreover, for "very low risk" men with life expectancy of 10-20 years, AS is the only option NCCN now recommends. "Very low risk" adds the following qualifiers: fewer than 3 positive cores (note:extra cores taken because of an mpMRI are not counted), <50% cancer in each core and PSA density <0.15). Most of the top institutions in the US follow the NCCN protocol. To my knowledge, the only AS program in the US that adds the qualification of unilateral cores is the Johns Hopkins program, which has the strictest criteria I know of. They also add age qualifications which are unjustified by any research data.

Given that you misunderstood all this, you may want to rethink your decision about treatment.