a friend of mine is on active surveillance.....

with the great Dr Peter R. Carroll at UCSF. I've seen this guy at the gym for maybe 15 years and I did a job for him this week and we discovered we both have/had prostate cancer.

he's only been on AS for about a year so he's a little emotional but I think he has the constitution to be on AS for the long haul and of course he's in the best hands.

his uro wanted to operate so he sought another opinion and that doctor also wanted to operate. persistence led him to Dr. Carroll and AS and I've given him my opinion on what I would do if and when treatment becomes necessary.

AS is the answer to the "overtreatment" issue we have with very low-risk PCa.

That said, just today I came across this somewhat disconcerting paper:

Redefining the Concept of Clinically Insignificant Prostate Cancer [2010]

"Abstract

Objective
To assess the risk of biochemical recurrence (BCR) in small low-grade prostate tumors following radical prostatectomy (RP), which are defined as clinically insignificant based on the existing criteria developed by Stamey and Epstein.

Materials and Methods
We identified 3784 men who underwent RP in Western Australia from September 1998 to March 2019. These patients had a Gleason sum (GS) of ≤6 or 3+4, prostate confined and negative margins. Pathological data analysis was performed using logistic regression modeling.

Results
Median follow-up was 96.8 months. BCR occurred in 110 men (2.91%). There was no statistical difference in the rates of failure for patients with a tumor volume <0.5 mL vs 0.5-2.0 mL when comparing (i) those with Gleason 6, or (ii) those with Gleason 3+4. Furthermore, there was no statistical difference in rates of failure when comparing patients with a tumor volume of ≤2 mL vs >2 mL when the percentage of Gleason pattern 4 was ≤20%. However, once the percentage of Gleason pattern 4 increased to 30%, there was a significant increase in BCR in the larger tumors (> 2 mL).

Conclusion
This study did not support either Stamey's or Epstein's criteria of insignificant cancer based on volumes of less than 0.5 mL, GS <7 and confined margin negative disease. No risk free cancer was identified, as all groups demonstrated some risk of BCR. This study redefines the entity of insignificant cancer as rather “low risk” cancer and expands its scope to include smaller tumors with minor Gleason pattern 4 components."

Djin

good to hear he was persistent.

And hopefully he listens to your experience in this game.

Sounds like AS is a good plan. And he obviously has a great doc and a great AS program.

Jim

As we have cited many times in here--there is no difference in mortality between those who go on AS and those who seek immediate treatment--and a significant percentage of those who go on AS never need further treatment--I think it's about 50-50 (half will never need anything additional, and half will).

The key is the Active part of AS. Regular PSA's, follow up biopsies, MRI's, etc.

If I were a G6 guy who was told I'm a good AS candidate, I'd sleep easier with an OncotypeDx or Decipher Biopsy test result showing that I'm not one of the roughly 10% who have a high risk of progression to lesions with a met risk.

Djjn

F8 said...

yep. "we" have all heard the horror stories of G6 guys who weren't G6.

There's that...missed high-grade lesions at the time of AS enrollment. But I'm talking about something else: men who were confirmed G6 post-RP whose Decipher test came back high risk. These are the 10% of men who are true G6, but who would likely not remain long in AS because of disease progression.

Djin

Post Edited (DjinTonic) : 2/10/2020 2:37:35 PM (GMT-7)

These were the recently published MSK results for their AS program

Long-Term Outcomes of Active Surveillance for Prostate Cancer – The Memorial Sloan Kettering Cancer Center Experience

Djin

halbert said...
With a good AS protocol, the whole point is to catch the progression if/when it happens to deal with it promptly. Decipher will help. I'm one of those who could have gone AS at the time of initial diagnosis (G6, all on one side, no core >25%, PSA 3.2 with saw palmetto present--so PSA was probably around 6.

I went for surgery anyway, and my final pathology was 3+4 in all 4 quadrants. I suspect--but will never prove--that if I had gone AS, the follow up tests would have found the 3+4 and ended the AS within a few months.

F8, as I recall, there was a long term AS study, oft cited on this forum. I believe it came from JH, and tracked their AS patients for a 10 year period--with those results. I'll see if I can find the link when I'm at home. In the end AS is a great choice for someone with a minimal G6 load.

ok. I don't disagree with AS but my point was AS isn't for everyone. if I knew I would need treatment in a year or two I doubt I would do AS. i'm just not wired that way.

and you gotta remember your first point of contact is a surgeon. my friend talked to two that wanted to snatch his prostate before he was referred to Dr. Carroll.

also, you probably have noticed that MOST guys who come hear seeking advice are leaning toward surgery even in cases where it makes no sense. at first most of us just want it out and our uro is glad to oblige.

AS in the right cases is great...but it's not for everyone.

F8, I agree. And, we have also discussed the psychological burden of AS--that some guys just aren't wired for it. I get it.

As far as urologists going from diagnosis to surgery in a blink of an eye--I'd like to think this is getting better, but who knows. I, personally, will always be grateful to my diagnosing uro who basically told me these points:

1. That I had a few months to decide what to do.
2. That if I wanted to go for AS, he would manage it for me.
3. That if I wanted open surgery, he would do it. (Small town hospital, no robot on site)
4. That if I wanted robotic surgery, he would refer me to a good one, and he would manage my post surgery care.
5. That if I wanted radiation, he would refer me, and would manage my post treatment care.

The longer I'm in here, the more I realize just how lucky I was to start with him.

Note that this was in a small town in rural Illinois, about mid-way between St. Louis and Indianapolis, 200 miles south of Chicago.

pasayten said...

F8 said...
age 57, G6, PSA 4, prostate size 40mm. difficulty urinating. that's all I know

Sounds like my stats at the beginning... Proved to be very pesky after RRP and SRT...

pasayten

I hear you. i'd probably go for SBRT and hope for one and done. one thing for certain. it doesn't get better the longer you wait.

halbert said...
F8, I agree. And, we have also discussed the psychological burden of AS--that some guys just aren't wired for it. I get it.

As far as urologists going from diagnosis to surgery in a blink of an eye--I'd like to think this is getting better, but who knows. I, personally, will always be grateful to my diagnosing uro who basically told me these points:

1. That I had a few months to decide what to do.
2. That if I wanted to go for AS, he would manage it for me.
3. That if I wanted open surgery, he would do it. (Small town hospital, no robot on site)
4. That if I wanted robotic surgery, he would refer me to a good one, and he would manage my post surgery care.
5. That if I wanted radiation, he would refer me, and would manage my post treatment care.

The longer I'm in here, the more I realize just how lucky I was to start with him.

Note that this was in a small town in rural Illinois, about mid-way between St. Louis and Indianapolis, 200 miles south of Chicago.

yeah you were lucky to get a good doctor. my doctor told me:

1) "you need to make a decision in two weeks, not two months"

2) "you will most likely need follow up treatment and I can't recommend surgery"

3) "once the target (prostate) is removed there's a greater likelihood of permanent SEs"

4) but if you don't want to wear diapers the rest of your life i'm your guy"

5) "the best news is your insurance will pay for everything"

"He hates the biopsy so much that he is considering surgery."

Yikes!