Dr. Epstein Webinar on Active Surveillance

Here is the video of Dr. Jonathan Epstein’s December 30th webinar on Active Surveillance. Epstein is the world’s most experienced prostate pathologist, and is considered the successor to the late Dr. Gleason.
A couple of things I noted:
1) He wants Gleason 6 to still be considered cancer, as 20 percent of the initial biopsies are incorrect, and men would not follow up if told not to be concerned. He does want a better explanation, so that men understand that they have low grade cancer,
2) He sees very low risk (small amount of Gleason 6) as the best AS patients. More Gleason 6 risk factors double the chances of reclassification. Also, men with any Gleason 4 pattern should only do AS within a clinical trial.
Webinar: Active Surveillance & Beyond - Dr. Jonathan Epstein - 30 Dec 20
https://youtu.be/pv532Jelw7k

I guess I missed this but I'll try to check it out. One of the few AS guys hanging around.

A very good presentation -- whether you confirm opinions and info you have or learn something new.

I was surprised about something Dr. Epstein said about transperineal biopsies after he brought up a known advantage -- easier sampling of the anterior prostate, where about 15% of lesions form. He said that all the statistical information we have on advising whether to treat or go on AS is based on the many years of TRUS (transrectal) biopsies, and we don't know whether this data applies to transperineal biopsies. For now I guess uros are assuming the data does apply, which is the logical choice until we have more data. But this is a very interesting point.

Some other tidbits I found interesting are

(1) Dr. Epstein is a one-man show! He doesn't have a team -- he personally examines the slides. If he's away for a lecture or another reason, he has one expert colleague that does the reading, but if you call and ask he'll tell you he'll be away so you can either wait until he's back or call after you get the results from the colleague and he'll review the slides himself and tell you if he agrees with the report.

(2) If you send slides to Dr. Epstein, have all of them sent rather than some. Sometimes he'll see something in a slide that was overlooked.

(3) Some of his re-gradings are the result of the artifacts of sectioning and staining done to make the slides. Another pathologist may have mistaken broken glands caused by the biopsy needle for a higher-grade cancer. He mentioned how he makes the call one way or the other. Dr. Epstein said that when he himself is uncertain between two grades, he will choose the lower cancer grade. His reasoning is that this will avoid overtreatment in some cases if the higher grade would have been wrong, and also the patient can have additional treatment at a later time if necessary if the lower grade is wrong.

Djin

Bobbiesan said...
...
One thing I had heard before, and still quibble with, is that one reason he wants gleason 6 to still be called "cancer" is that it encourages men to still watch their situation and get regular future checkups as their docs advise. I personally would prefer "just the facts", untainted by agendas. But whatever. It was a good webinar.

Robert

That begs the question of what to call it -- what to tell patients they have. The "facts" are rather difficult to summarize for many without some background. G6 may remain indolent or it may grow out of the prostate and spread locally. There is no way if knowing with certainty if a patient with G6 currently has lesions of a higher grade. And about 10% of patients with only G6 lesions currently fully confined to the prostate have tumor RNA defects (identifiable with genomic testing) that make them high risk of forming lesions of a higher grade with a high risk of metastasis within 5 years (if the G6 spreads from the prostate, the risk goes up to about 17%). Even among those who remain in AS, about one-third will need treatment for prostate cancer.

Epstein and colleagues make the full case here:

Should Gleason 6 be labeled as cancer? (2016)

where they do present "just the facts." But one is still left with the naming decision. In the Webinar Epstein discusses this naming problem, but I wouldn't say he has an agenda. Rather, he wants to ensure that G6 men are informed about AS and how good a candidate they are and, if they choose AS, are monitored actively so they know if and when they need treatment. He believes this is best achieved by labeling G6 as cancer. He also stresses that some men whose pathology makes them eligible for AS are not good candidates psychologically.

Djin