Another study showing no increased risk from appropriate Active Surveillance

[Guest guest]

Many of the arguments against Active Surveillance seem to be based on the fear of losing a window of effective treatment-- to the effect that there simply is too much risk of developing aggressive and lethal cancer if one does not get treated soon after diagnosis. Hopefully those offering anecdotes of cases where prostate cancer quickly turned lethal realize that none of these where the diagnosis was not low risk cancer--Gleason sum greater than 7, PSA greater than 10, more than 50% of cores positive, PSA density greater than 0.15-- were ever candidates for AS in the first place. Hopefully discussions of the pros and cons of AS start with acknowledgement that the classic D'Amico risk classifications- Low, Intermediate, and High Risk- are accepted by virtually all prostate cancer doctors, irrespective of treatment biases, as staging tools for selecting treatment options. Not perfect, but as yet none of our prostate cancer tools, including all treatment options, are 'perfect.'

I don't know if such arguments are based on still confusing Active Surveillance with the older Watchful Waiting (do nothing until clinical symptoms develop), or, if they simply are based on personal risk aversion. If it is the latter, then this is part of the personality/life style analysis that should always be part of evaluating what prostate cancer treatment is best for each individual. However, one would hope that such personal traits are not used to condemn any particular treatment option for all others.

Either way, the number of studies continue to increase showing that, FOR APPROPRIATELY SELECTED LOW-RISK CANCERS, deferring treatment until the monitoring shows treatment is appropriate does not increase the risk of aggressive cancer, nor of increased risk of mortality from prostate cancer. And, the increasing number of well-monitored Active Surveillance programs HAVE developed criteria to assess when it is time to get treated.

The abstract below on the experiences at UCSF show similar outcomes to AS programs at Sunnybrook (Toronto), s Hopkins, and Royal Marsden (London), among others.

Each of us needs to make our own decisions on how to treat our individual diseases. However, one hopes that such decisions are based on the best available information, not just initial shock and fear of being told you have the "Big C".

The Best to You and Yours!

Jon in Nevada

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Surgical management after active surveillance for low-risk prostate cancer: Pathological outcomes compared with men undergoing immediate treatment - Abstract BJU Int. 2010 Aug 26. [Epub ahead of print] Dall'era MA, Cowan JE, Simko J, Shinohara K, Davies B, Konety BR, Meng MV, N, Greene K, Carroll PRDepartment of Urology, University of California, , CA, USA.

To compare the pathological outcomes of men undergoing radical prostatectomy (RP) after a period of active surveillance (AS) with those of a similar risk group undergoing immediate surgery.

We identified men through our institutional database who underwent RP within 6 months of diagnosis or after a period of AS. The primary outcome of the present study was Gleason upgrade to >/=7 after prostatectomy. Pathological stage and positive surgical margin rate were assessed as secondary outcomes. Binomial logistic regression models were used to determine associations of treatment subgroups with pathological upgrade, upstage and positive margins.

Thirty-three men with initially low-risk cancer features underwent RP after a median (range) of 18 (7-76) months of AS. A total of 278 men with low-risk disease features underwent immediate RP within 6 months of diagnosis. Rates of Gleason upgrading to >/=7, pathological category pT3 and positive surgical margins did not differ significantly from the immediate RP group. On multivariate analysis of low-risk patients, adjusting for baseline pathological features, treatment group (AS followed by prostatectomy vs immediate prostatectomy) was not associated with Gleason upgrading (odds ratio, OR, 0.35; 95% CI, 0.12-1.04), non-organ-confined disease (OR, 1.67; 95% CI, 0.32-8.65) or positive surgical margins at prostatectomy (OR, 0.95; 95% CI, 0.16-5.76).

The present analysis did not show an association between RP after a period of AS and adverse pathological features for men with low-risk disease.

doi: 10.1111/j.1464-410X.2010.09589.x PubMed Abstract PMID: 20804478