This is an interesting interview. Although I fully believe in his honesty, it is also worthwhile to consider that AS ain't cheap. Also, he doesn't discuss hoe much better we do recovering from potential SEs when we're younger. That, in my opinion, should be a strong consideration. Not to mention that so many of us recover so well from treatment anyway.
Andrew Schorr:
You have a center where you've really thought about
this a lot. For your patients who are having active surveillance, how frequently would they see you, and what sort of checkups would they have?
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 emphasize the diagnosis has to be made as a product of a very good biopsy. So sometimes if we're not quite sure that the biopsy technique was adequate we'll go ahead and repeat the biopsy just to be sure we're not what I call "under-grading" or under-staging that patient.
Now, active surveillance is being done at many centers, not as many that it perhaps should be, but centers here in the United States and in Canada and in Europe. No one knows the best way to follow patients, but here at UCSF we get PSA tests and blood tests done every three to four months, serial imaging with a Doppler ultrasound actually is a pretty good test so we do that at six-month intervals, and we usually repeat the first biopsy at 12-24 months. Then depending upon how long the patient has been on surveillance, we extend the time interval between evaluations, so it's really a product of blood testing, physical examination, imaging, and every now and then a repeat biopsy.
Andrew Schorr:
And that could go on for years.
Dr. Peter Carroll:
It could. Certainly patients who are older or who have other medical diseases may be very good candidates for active surveillance, but even some very young men we're seeing with small, low-grade tumors we've put on active surveillance. For those men it's not so much are they going to be treated or not treated because if you're in your 40s and 50s and have a low-grade cancer well I think you're going to live a long time, and even a slow-growing tumor may get to the point that it will need treatment, but a lot of these young men may not have completed their families; there are side effects of treatment, and would like to put off treatment if they can to complete some important life events.
Andrew Schorr:
Yes that was my question. If someone might say, well if I'm going to need treatment some time what's the downside of having it now? Let's just go for it. Help us understand. I know there's no sort of free lunch with the treatments that you have. There are side effects. There are concerns.
Dr. Peter Carroll:
Any treatment no matter how well delivered can be associated with some side effects, and we try and limit those side effects, but they may be present. So the thought of course is that if we can delay treatment without compromising overall outcome, let's go ahead and do it and again this is especially for patients who might older or have other medical illnesses.
We do realize that there are some men, even though they have very little risk of progression, who just do not deal well with active surveillance. For those men, their mental health improves with treatment, and we recognize that and do understand that all men may not be or feel very well suited to active surveillance.
I think the more information that comes out on active surveillance the more that physicians with expertise in this area expand their programs and patients we have found actually adapt well to it. So you can minimize the anxiety associated with surveillance by putting a little bit more time and effort into educating the patient and their families. A lot of the patients' families are the most aggressive ones in advising treatment compared to patients themselves.
Andrew Schorr:
So this concept of active surveillance is a treatment option in a way. It's part of the treatment plan.
Dr. Peter Carroll:
Correct. 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.
www.ucsfhealth.org/education/interview_carroll_active_surveillance_for_prostate_cancer/index.html