'AS 2022 in Review': Active Surveillance in the news

And whassup up in 2023? Plus we're #1--read on.

Dec 29, 2022

(“We’re #1! We’re #1!” This is like winning the Academy Award, the Tony, the Super Bowl and the World Cup combined in the world of active surveillance and medical publishing. Congrats to Dr. Scott Eggener, et al. (including me, The Active Surveillor). We co-authored the top-read paper in the Journal of Clinical Oncology in 2022. The article has triggered a debate on whether Gleason 6 should be considered cancer at all. We say not. Read the journal article here. Are we going to Disney World? Or at least ASCO (American Society of Clinical Oncology?) Read more about the debate below.)

By Howard Wolinsky

As a veteran news reporter and a rare career journalist, I have written hundreds of year-end roundups for the newspapers I have worked for my over 50 years on the job.

(I have carpal tunnel, cubital tunnel, an arthritic back and papercut scars to prove it. Not complaining. These are my badges of honor.)

I’m going to list some of my favorite AS stories of 2022. If I missed any, please enter a message in the comment box.

Drum roll, please in no special order

--#1 A record proportion of low-risk American patients have gone on active surveillance (AS). But it still sucks. In 2021, nearly 60% of us opted for AS. Better than the 6% of us who did in 2010, but behind the 94% who do so in Sweden, the Land of AS. Flip the numbers, and you’ll see that up to 40% of U.S. patients with low-risk disease are being treated unnecessarily. (Note: AS isn’t for everyone, but should work for most.)

--#2. IsoPSA, a new type of PSA test developed at the Cleveland Clinic, is reducing by half the proportion of patients who on to have biopsies.

The National Comprehensive Cancer Network (NCCN) has recommended the IsoPSA test as means of helping patients and doctors decide whether they need a biopsy. This test so far is for those with rising PSAs and not those on AS. But research could change that. But some AS patients are opting for IsoPSA.

--#3. Despite the harping on being sure to get a Tesla 3.0 mpMRI, a Tesla 1.5 can get ‘er done, a UChicago medical physicist told The Active Surveillor. He also warned about the manufacturers engaged in a war of more powerful magnets with loads of bells and whistles when what’s needed is a cheaper, simple 1T prostate-only scanner.

(The Perfect 10)

--#4. A UMichigan expert says patients tend to be literal about PSA levels and worry too much if they are approaching the high end of the gray zone--PSA 10. He doesn’t worry until PSAs hit 15. PSA is just one factor in the mix. Check here.

--#5. Your PSA may actually be lower than you think. A friend of mine from Ann Arbor, Michigan, (Go Blue!) was freaking out as his PSA reached a 10. Suddenly, his PSA dropped 25%. Why? His lab, like many others, switched to the WHO (World Health Organization) standard. So ask your lab what standard they follow. Many are moving over to WHO. My friend “Steve’’’s PSA dropped from around 10 to 6.6. More recently, it was 6.1. Maybe it’s just a numbers game, but Steve is feeling good about it. Check here.

(Nature Review/Prostate)

--#6. Why can’t the USA be more like Sweden? Active Surveillance uptake rate there is 94% for patients with low-risk prostate cancer (Gleason 6). Sweden has a national health plan. Is it because docs are paid the same whether they do surgery or not? I don’t think so. The state of Michigan’s MUSIC project, sponsored by Blue Cross/Blue Shield of Michigan, shows that even in the U.S., a 91% AS uptake can be achieved with a mix of private, academic, large, and small urology practices. Here’s a webinar on moving the needle for AS,

Michigan is also breaking records with AS for favorable intermediate-risk (Gleason 3+4) prostate cancer.

--#7. Emotional distress (stress, anxiety, and depression) and prostate cancer finally are starting to become a priority. The Active Surveillor covered this topic numerous times. Hell, even our urologists have stress issues, topping the list of stressed-out professionals in a federal study. Maybe now that the uros are getting stressed they’ll pay attention to anxious surevillance?

It’s on the agenda for 2023.

--#8. The Active Surveillor shined a light on AS’s “dirty little secret”--the huge dropout rate: about two-thirds of us drop out of AS within 10 years of being diagnosed. Prostate cancer progression, rising PSAs, emotional distress, AS exhaustion and patients going on “watchful waiting” are among the reasons.

So much effort goes into getting patients to accept this seemingly crazy notions that we can live with these cancers and that Gleason 6 lesions most likely will never spread or kill. More research needs to be done on finding which patients should or should not go on AS and on separating the aggressive wolfish cancer cells from the sheepish cells. How can more patients overcome emotional distress and exhaustion to stay on AS?

--#9. Active Surveillance 101, a series of videos to provide expert information on AS to the newly diagnosed and those in the limbo of the grey zone, was launched in 2022 by the Active Surveillance Coalition. Active Surveillance Patients International, AnCan, Prostate Cancer Support Canada, Prostate Cancer Research Institute, and TheActiveSurveillor.com are the sponsors. To get a preview, go to aspatients.org and look under events. Early next year, at least six programs will be available. Watch this space.

--#10. Riding a bike and ejaculating within 48 hours before PSA blood tests can raise your levels. But did you know that research has shown that PSAs are higher in the spring when the sap is running and on Thursdays and Fridays apparently as we’re thinking about the coming weekend? Meds are another gremlin that can cause PSAs to rise—or fall.

Whassup in AS in 2023?

Happy 2023!

What’s happening in Active Surveillance in 2023?

I’ll peer into the crystal ball and take a stab at it:

—The American Urological Association will be coming out with new early-detection guidelines, their first in seven years. I hope that they endorse transperineal biopsies--as has the European Urological Association--to try to stop deadly sepsis from transrectal (transfecal) biopsies.

For an overview of the transperineal v. rectal debate go to: https://bit.ly/3HYxDPn

—I’m also hoping urology will get serious about reducing antibiotic use to help eliminate antibiotic-resistant organisms that pose a major public health threat.

Is “Big Urology” ready for reform? We’ll see.

—I also hope AUA and ASTRO, the leading doctor associations in the “prostate space,” will join with other organizations in addressing the emotional distress (stress, anxiety, and depression) epidemic in patients with prostate cancer. It’s time that existing guidelines calling for screening of distress, such as those from the National Comprehensive Cancer Centers and the American Society of Clinical Oncology, be applied. Check out this story.

Many of you participated in a survey AnCan, ASPI, Prostate Cancer Support Canada and The Active Surveillor conducted last fall. One of the key topics covered in the survey was emotional distress and people on AS. I can’t share the results yet but the survey results will be making big news. (Easy prediction.)

—I also expect to hear more about the advantages of MRI, “liquid biopsies” and other methods to reduce the need for biopsies of any kind. Progress is being made in these areas.

—There will be more in 2023 about the movement to reclassify Gleason 6 as a non-cancer.

A survey in The Active Surveillor earlier this year showed patients are divided about this idea. Dr. Scott Eggener, of UChicago, has been campaigning for this change. He and other top docs and The Active Surveillor co-authored a paper in the Journal of Clinical Oncology in 2022—See the intro—asking that Gleason 6 be reclassified as a noncancer as Gleason 5 was. The piece has had a big reaction. Lots of eyeballs and opinions. It was #1 paper in the journal in 2022.)

Top gun pathologist Dr. Jonathan Epstein, of Johns Hopkins, is arguing in favor of the. status quo. Dr. E., a TAS subscriber, asked The Active Surveillor to cover his side of the story—even though we’re on the other side. Of course, we did. The Active Surveillor is “fair and balanced.”

Again, the survey will make news with your views about this controversy.

—I hope that some celeb finally fesses up to being on AS. Star power can shine a light on a health problem and also draw research funding. The squeaky wheel gets the grease. We need a Michael J. Fox for AS. We only know two major actors on AS. One has talked about it. The other avoids it. No doubt in 2023 we’ll hear about other celebs who are being treated for more aggressive cancers. They all should Rage Against the Prostate Cancer Machine and help fellow patients.

Science has proven one member out of two rock bands will be diagnosed with prostate cancer. Some are bound to be AS candidates. (Actually, 55% are. But where are they?)

Have a great 2023.