Safety of Active Surviellance

The point that Peter and AN38 bring up is the same one that I was trying to make earlier. Biopsies are very often inaccurate and understate the aggressiveness of the desease. My biopsy was a 3+4=7 but patholoy showed it to be a 8. If i chose AS based on this biopsy I may have been in real trouble today. I understand that there are other tests to determine the agressiveness of PCa. One has to be very careful in going AS.

I agree with the point that 7 years is about what an AS patient should expect to get before treating their disease. The question is whether they missed an opportunity for a local therapy as in the case I linked. The other question remains "does it affect prostate specific mortality" Neither of the cited studies show any of that. In fact one of the studies admits it lacks that information. The UCSF study shows that 18 months delay before therapy is safe. I pretty much don't argue that point. It would be a misuse of either study to say they show that AS with delayed surgery have the same mortality results.

Additionally, from the many studies I have, and most publications, 75%, or much higher, of patients treated with surgery have full urinary control by the end of the first year. Far less than 50% still have ED issues at year two, and most that do have success with ED drugs, injections, pumps, etc. A top line surgeon can help these numbers improve as well. Here is good information from an excellent website:

Unrinary Dysfunction: www.pcf.org/site/c.leJRIROrEpH/b.5814053/k.1572/Urinary_Dysfunction.htm
Erectile Dysfunction: www.pcf.org/site/c.leJRIROrEpH/b.5836625/k.75D7/Erectile_Dysfunction.htm
Bowel Dysfunction: www.pcf.org/site/c.leJRIROrEpH/b.5836623/k.B486/Bowel_Dysfunction.htm

I would be interested to see a study comparing the side effects of immediate versus delayed therapies. Perhaps we have similar data, perhaps we don't recover as well when we age. If I was a betting man, the latter would have my money...

Tony

Welcome Mike,
You would want to look at PSA doubling time. You have enough data. Your Gleason is 3+3 but your cancer may be behaving like there some higher grade stuff at work. You have time to do research, but you are outside the criteria for active surveillance typically. You can look at the example case I showed for Terry Herbert there is a nifty PSA chart there. Additionally, you can predate AS to when you started seeing the low Free % PSA.

Good luck in the coming weeks. Perhaps you have already looked into a therapy of choice, but if not you probably should. You start pushing PSA's into the teens and you will start seeing more adverse outcomes.

Peace and welcome again,

Tony

Mike,

I also had a large prostate.  My urologist recommended brachy preceded with hormone therapy to reduce the size of the prostate.  I know other large prostate posters on this site have chosen the HT/Brachy approach and been satisfied with the result. 

You may also want to investigate the possibilties of some of the focused enegy treatments (i.e. CyperKnife, Cryo, etc.).

I chose to be DaVincied and have been satisfied with the results (to date).  The large prostate did not seem to hamper the surgeon. 

John, I think that you are using data very selectively. All the data I have read on urinary issues is much better than 70% incontinance over time. It's more like 10%.

Cancer, including prostate cancer is a progressive disease. This is also a fact uncoloured by emotion. It's just that the rate of progression in prostate cancer is slow for low risk patients and older patients are likely to die of something else. Also not under question is that "low risk" is defined by tests that have been proven to be incorrectly classify patients in a substantial minority of patients.

Reading your thread you would think that there is no place for surgery, that there is no benefits and substantial risks because it all would have been the same anyway if you treat now or at seven years time. But the fact is that PC is a slow growing disease not a stationary one. Over time treatment options will narrow. Also not under question is the fact that the %s of side effects to surgery worsen as the patient gets older.

John, this is not as black and white as you would like it to be. Many especially younger people would prefer the risks of surgery, even though they may be facing chronic syptoms or positive margins against the real risk that in seven years time they may be dealing with advanced disease. So are they wrong? If you are an epimediologist and looking at populations of people then the answer is that we are overtreating this disease. However if you are an individual patient you have to to examine the data, your age, the likely characteristics of the cancer, your appetitie for risk, your appetite for the potential side effects of various options and make a call.

An,
I respectively disagee with you. Using the defination of 2 pads a day the contintance rate is about 90% at 2 years. If using pad free it is 69% in two years, and using no pads, no leaks it is 28%, (Reynolds, the new Prostate cancer info link nov 16, 2009,)
There is very little improvement after 2 years. Impotence also has different definations, such as the ability to have an errection with meds once every two weeks. The devil is in the details and how they are defined.
Not all prostate cancer grows slowly, some grows fast and others don't grow at all. If PSA doubling time is less than 3 years you have to be treated. 4 to 6 years it's a toss up depending on age, and over 7 years you can most likely go for the rest of your life. Many cancers are stable and don't grow at all for decades. If you show any signs of progression, increasing psa doubling time, tumor growth on a color doppler or gleason change on a biopsy from 6 to 7 you need treatment. If none of these are present you don't need intervention. Getting intervention later is just as effective as getting it immediately if properly monitored.
My views on surgery have been stated many times. It is appropriate for younger men with confirmed contained PC that is not near any any place that would make a positive margin unlikely. It is also appropriate if used as a dubulking procedure for high risk patients. Brachytherapy and IMRT have similar or better cure rates with all grades of PC with much less long term side affects than surgery.
We can disagree, as many experts do; but I feel that AS is a safe and appropriate course of action for men with low risk PC that meet the criteria as long as they are monitored by a doctor experienced with AS. The medical community is rapidly adopting this approach that was considered totally out there 5 years ago. Many noted doctors, such as Scardino, Carrol and Epstien have recently come aboard with this approach. As as data from studies at Hopkins and UCSF become available I think it will become standard practice within 5 or 10 years.
JT

well said an38

An, I think your posts are a bit unfair to JohnT.  What John has pointed out is that active surveillance is an appropriate option to be considered for men with early stage prostate cancer.  He joins a growing list of experts and studies who state that position.  Don't shoot the messenger.

We can all quibble about the side effects of various protocols and our value judgements about whether those side effects are acceptable or not.  One of the links Tony provided on this thread showed that 30%-60% of men who have surgery will return to their pre-surgery sexual functionality after two years.  Is that good?  It's in the eye of the beholder.  The 2008 study on quality of life of prostate cancer survivors that was published in the New England Journal of Medicine showed that two years after surgery 64% of the men reported "erections not firm" and 43% reported "overall sexuality problem".  The same study showed 20% of post surgery men still using pads at the two year mark.

The point is that there ARE side effects to any treatment...surgery, radiation or whatever.  For men who meet the criteria, Active Surveillance is something that should be considered...that is what John has said eloquently many times on this forum.

Tudpock (Jim)

John & Tud,
I want to thank you both for the comments. The counterpoints offered in this thread are a great read.

Side effects exist in all treatments for prostate cancer. And if we are in agreement that AS is a temporary game for most then these side effects are unavoidable for most. It would be unfair to tell people they should do active surveillance without providing all of the facts about it. The facts are that the studies are ongoing. The facts include that more than half will opt out for a treatment option by year 7. Some will progress straight to systemic therapy. Some will die of prostate cancer. The fact is that AS, while safe in appearance has as many unanswered questions about it as a new treatment therapy that has not gone through the trial phase.

I have outlined what I thought was a very sensible program for AS in this thread. But I can't take too much credit for it, It's what most of those growing experts agree is sensible. Is it for everybody with low risk disease? You'll have to excuse me for standing on the fence and entertaining both sides of the argument.

Tony

Tony and JT, I agree with both of you about the benefits of having a forum that allows us to explore the many facets of PCa.  In this spirit, I offer the following link on the subject of Active Surveillance. 

http://www.medscape.com/viewarticle/715129

In this article, Dr. James Mohler, who heads the Department of Urology at Roswell Park Cancer Institute in Buffalo states that Active Surveillance could be the sole initial treatment for as many as 40% of the PCa cases diagnosed in the USA each year. And, Dr. Laurence Klotz of Sunnybrook and Women's College Health Centre in Toronto states, "No one is harmed in their curability by an 18 month period of observation".  He says that in reference to early stage cases in encouraging that time be allowed to assess PSA doubling time.

Of course one may disagree with their conclusions but they are two of many who are encouraging further use of active surveillance on low risk patients.

Tudpock (Jim)

David,
I don't agree that any form or treatment should be forced upon any patient for any reason. I know insurance companies do this frequently and the government will end up doing it someday. I want the freedom to pursue the couses of action I choose. I also believe that every patient has the right to all information regarding his course of action, and this is an area that I feel the medical community is sorely lacking in.
The side affects of every treatment should be thouroughly discussed and what consititutes impotance or incontenance be explained. Patients should also be told that before having bone or CT scans for low or intermediate risk PC the accuracy is about the same as a coin flip. The benefits of AS should be explained throughly as well as the benefits and risks of treatments. The choice and benefits of having additional tests such as Color Doppler and MRIS or ploidy analysis should be given to all patients before treatment. 2nd opinions from all different fields should be encouraged. Lastly I feel that for prostate cancer, like every other cancer, the primary doctor should be an oncologist, not a radiologist or a surgeon who have built in biases. There is no other major cancer in which a surgeon is the only doctor that a patient will see and there is something that is definately wrong with this. Why is prostate cancer treated differently from other major cancers? If these are put into place I believe the standard of care for all patients will be noticiably improved.
As always, these are my opinions and not held by the majority.
JT

Tony,
You misunderstood what I said. I was responding to David's suggestion that all men with low risk PC be forced to undergo a waiting period. I don't agree with this.
I certainly don't agree that the majority of patients reviewed all of their options before deciding on treatment. Some patients, especially the ones on this board and the ones you have contact with in support groups have investigated and made a rational choice, but the vast majority just go with what their urologist recommended. This is especially true with older patients and patients that are unfamiliar or uncomfortable with doing their own research and take their doctor's recommendation as gospel.
There are only a few thousand individuals who visit the various forums and support groups vs millions men in the US that have been Dxed with PC.

JT

An, I appreciate your perspective but still fail to see what is so troubling about JT's message.  What I get from it is that he is trying to educate folks on this forum to understand that active surveillance is a perfectly reasonable option for low risk PCa patients to consider. What's so controversial about that?  BTW, there already is a clear third category in which many of the folks who visit this forum fall.  That is, after the initial shock, to work like heck to become educated about the disease and then make a fact-based decision.  That is certainly what you did, as did I, JT, Mel, Franchot and many others.  We didn't all pick the same treatment but we did study the options to death so that we were comfortable with our choice.

David, I am actually somewhat conflicted about your suggestion.  Like John, I don't believe that any man should be forced into a decision.  However, if I was the Medicare Czar or King of Health Care Cost Reduction, I must admit I would be tempted to determine that some treatment plans for "very low risk" PCa diagnoses would be treated as elective rather than automatically paid.  Interesting issue...!

Tudpock (Jim)