Active Surveillance Update - 99.9 Percent Will not Die from Prostate Cancer

I am all for AS for those who truly qualify.

I am confused on one aspect. I thought that a 3+3=6, if properly diagnosed, would never advance to more than a 3+3=6. I also read where at some point they wanted to rename a 3+3=6 to a disease, instead of calling it cancer.

So, my question is... is the cancer advancing or was it misdiagnosed to begin with? And, does a true 3+3=6 forever remain a 3+3=6 or does it morph into something more dangerous?

MsWorryWart said...
I am all for AS for those who truly qualify.

I am confused on one aspect. I thought that a 3+3=6, if properly diagnosed, would never advance to more than a 3+3=6. I also read where at some point they wanted to rename a 3+3=6 to a disease, instead of calling it cancer.

So, my question is... is the cancer advancing or was it misdiagnosed to begin with? And, does a true 3+3=6 forever remain a 3+3=6 or does it morph into something more dangerous?

Naturally, any biopsy reports showing a G6 or less can miss a G7-9 that is hunkering down inside the old prostate. Which is why a fair %(20%?) of men are upgraded after they get their post op pathology results.

Be careful how you interpret the John Hopkins AS study. If you just buy into the headlines it can be misleading. This was a well designed study conducted at John Hopkins by some of the finest clinicians in the world but the patient inclusion criteria, study design and exclusion criteria is not something that happens typically. AS may be an appropriate treatment for some but only when you entrust that your clinician will not miss the window of opportunity to re-classify your cancer as times pass by.

Ms WorryWart said...
I am confused on one aspect. I thought that a 3+3=6, if properly diagnosed, would never advance to more than a 3+3=6. I also read where at some point they wanted to rename a 3+3=6 to a disease, instead of calling it cancer. So, my question is... is the cancer advancing or was it misdiagnosed to begin with? And, does a true 3+3=6 forever remain a 3+3=6 or does it morph into something more dangerous?

You got it part right, part wrong, imho. A GS3+3, if properly diagnosed, cannot metastasize. That is, when metastases are detected, they are always found to be associated with a higher Gleason score than 3+3. While one can never be fully certain from a biopsy that there is only Gleason pattern 3 within the prostate, when higher Gleason patterns are found on f/u biopsies, it certainly may be the case that the cancer has progressed. Some GS6's probably do progress (although there's some evidence that higher grades may emerge in parallel, at least sometimes, from a common ancestor cancer stem cell). Some GS6's never progress. It seems now from these long-term AS studies that about half of them never progress. We have a couple of tools (Prolaris & Oncotype Dx) to help distinguish the GS6 progressors from the GS6 non-progressors. Or, we can just watch it closely on AS to see if it does, and treat it then - without any cost in survival.

- Allen

Worried Guy,

This post is entitled: "Active Surveillance Update - 99.9 Percent Will not Die from Prostate Cancer"

Maybe because I am so involved in AS that the meaning is obvious to me. Clearly, your background and perception/comprehension differs from mine.

I believe that the wording is clear, and if you have a contrary opinion, that's your prerogative, but it doesn't persuade me.

Again, you are missing the purpose of AS.
AS is a protocol, whereby closely monitoring the cancer of selected low risk patients those that truly need treatment can be separated from those who need no treatment.
We know from 20 years of history and countless studies that approximately 30% of those Dxed with low risk cancer will progress, either through an upgrade in Gleason grade or a faster growing tumor reflected by a rising psa. these progressing patients are then treated with results similar to those originally Dxed with low risk cancer and treated immediately. The lifetime risk of dying for the total of patients selected is less than 1% including those treated and thaws never treated.
There is evidence that G6 will rarely matastize and the vast majority of upgrades are due to biopsies missing the upgraded tumor on the first try. There are rare cases in which it is believed the cancer may have morphed into a high grade, but little evidence to support this claim.
What this study does show is that AS is very safe and much less risky than most men believe.
JT

Jeff,
The term Active Surveillance already means all those things you put in bold type, and requires no "tag line." Perhaps you might understand it better if you review the description of it in the sticky for the newly diagnosed.
- Allen

Your question, at least to me, is unclear.

I think you are asking/clarifying this point, which is a correct statement: Men who were on AS but later moved to a deferred curative treatment have essentially the same outcomes as those with the same initial diagnoses who went for immediate treatment.

Was this your point/question, Paul65?






Of course, one of the key unsaid parts is that there's a whole boatload of men who went onto AS and never pursued aggressive treatment, nor suffered the harms associated...

BillyBob, it is continued good news for low-risk men.

Other less restrictive programs have similar good news for intermediate favorable risk men.

Paul...yep, you're on track and it sounds like you have the right temperament if you qualify for AS. A lot of guys here just aren't wired that way, which I completely get. For my part, I believe I would have jumped on the AS train if I had qualified, although it's impossible to say for sure since I never faced the option. I also suspect that I would have faced some opposition to that approach from well-meaning friends/family since I think it's a natural tendency to want to do something when faced with cancer.

In your case, we all clearly hope that you don't have any cancer. But if you do end up with a low-risk diagnosis, yes AS could be your ticket.

When dealing with real world data it is generally true that if you aren't at least somewhat confused about the details it simply means that there are things you haven't considered. We have touched on a number of topics here where the simple understandings are simple, in part, because they leave things out.

The study at hand shows that men who are selected for the Active Surveillance program at Johns Hopkins are very, very unlikely to die of prostate cancer or even to develop metastatic disease. It's quite a strong result. But also a rather narrow one.

To see what I mean, consider the two titles I have found for this article. In Science Daily it is

"Some with low-risk prostate cancer not likely to succumb to the disease"

while the title to the Hopkins announcement is

"Men with Low-Risk Prostate Cancer in Active Surveillance Program Not Likely to Succumb to the Disease, Study Shows"

Notice that the Science Daily title, which seems to be reaching for a broader applicability, doesn't actually say anything? Some men with low-risk disease don't succumb? If the term "low-risk" has any meaning then the statement doesn't seem to need any proof. I like the Hopkins title better because it tells us which men we are talking about. Men enrolled in a single, specific Active Surveillance program -- the Johns Hopkins program -- do really, really well.

Presumably, similarly selected men enrolled in similar AS programs also do well but the study under discussion doesn't speak to that. And, actually, when describing the two men who did die of prostate cancer in their study

the article said...
In the second man's case, Johns Hopkins doctors recommended surveillance, but the patient sought monitoring at another hospital and died 15 months after his diagnosis.

so there you go.

The other difficult to understand topic is the "Gleason 6 Never Metastasizes" thing which is even harder to understand. The problem with that one is that it sounds like a statement that looks forward in time but it is actually based on data that looks backwards. A more accurate description of the result is "If there are metastases present then there must also have been Gleason >6 disease present if you go and look for it."

It is also a very strong result but is almost universally misunderstood.

InTheShop said...
I don't understand this thread.
I feel miss understood.
I am going to have a beer.

Andrew

One of your best poems yet!

Tudpock18 said...

P.S. For those of you wondering about the age issue, the median age was 66 -- the range was from age 41 to age 92. So JHU DOES admit young men into their program if they meet the other criteria.

Jim, that's a great clarification. BTW, the median age for the study matches almost exactly the median age for PC diagnosis in the US.



We also have an excellent reference source for newcomers or anyone who seeks knowledge and information about PC...it's a sticky thread at the top of the page, titled, "Newly diagnosed with PC - read this thread first." The question of age was also well-covered in a post in that thread; repeated here for reference, with bold added by me for emphasis:

Casey59 said...
It should be noted, however, that there currently is no universally accepted formal protocol for AS entry, monitoring, or exit; rather, attending clinicians tailor a program of care unique to each individual case but based on common foundations. While age is a consideration in some programs, Dr Laurence Klotz, considered a foremost authority on AS, has expressed that "the longer the patient’s life expectancy, the more stringent should be the AS criteria, but youth alone is not a contraindication for AS." Also worthy of note is the recognition that Klotz's program, and others, are now evaluating limited inclusion of men on the low-side of INTERMEDIATE-RISK PC (small amounts of Gleason pattern 4, and otherwise low-risk case characteristics).

Post Edited (JackH) : 9/2/2015 1:16:12 PM (GMT-6)