Thanks, Rick. Not sure if you mean small practices in the community or large private practices. I understand that just by sheer numbers it is likely that large private practices may do most AS. Doctors but also patients and patient families play a role in that 40% number. Anxiety and depression need to be addressed head on. It's hard for some to accept that they can co-exist with a "cancer," even a low-grade one. like Gleason 6.
The elephant in the US community medical office is financial conflict of interest!
Beyond the broad 'ethics' reference, it is not named per se.
As advocates, we must repeatedly remind community urologists and radiation oncologists treating prostate cancer that we are on to them. It is not just about amortizing their very expensive equipment and paying their bills.
The more we as patient advocates remind practitioners, and the more patients question why a procedure is necessary, the more likely we'll drop that 40% rate to 4%.
In a general sense, all of this has to do with a lack of understanding about prostate cancer. Education about PCa should ideally begin in the primary care physician's office where there should be adequate information concerning the PSA that your PCP recommends. And then there, and not only in the urologist's office, information concerning PCa should be available. Etc., etc.
After reading the European Urology article, the main reason these patients are opting for treatment without biopsy is avoiding biopsy morbidities, not “seeding“ of cancer. Given that the sensitivity and specificity of combined mpMRI and PSMA-PET/CT is so high (pratically 100%), skipping biopsy seems reasonable, but only if you opt for RP. To justify AS, you still need a Gleason value from a biopsy. As for RT, the Gleason value is traditionally used to decide if neoadjuvant ADT is necessary, but the study by Yang et al. (European Urology, 2019) casts doubt on whether ADT is useful at all in combination with RT for high-risk PC, and perhaps even counterproductive. If you accept their argument, then biopsy could also be skipped if high-quality mpMRI and PSMA-PET/CT results were available and the PSA also pointed to high-risk PC (PSA>20).
So the only justification remaining for biopsy would be avoiding treatment at all and opting for AS.
The question still remains why anyone is still opting for RP, a clearly inferior treatment. Just avoiding biopsy is not a sufficient reason.
Thanks for the additional comment. When I spoke with the surgeon, he emphasized patients fear of seeding. He said they also we were not candidates for AS.
As to moribidities ... like sepsis? --The German doc said they weren't a concern. He said a transperineal biopsy would not have satisfied these patients.
The article does mention tumor seeding among other issues:
“ Several benefits are arguable: no further complications after biopsies, reduced time from diagnosis to treatment, lower psychological burden, and anxiety in patients (ie, anxiety about biopsy-associated pain/complications and tumor seeding), and lower health economic costs (cost of additional PSMA-PET vs cost of unnecessary biopsies).“
These other issues do strike me as legitimate concerns. If one could do away with biopsies, all the better. However, this should not be made into an argument for RP and against AS or RT. In fact, in my humble opinion RP should long ago have been rejected as an inferior treatment just as radical mastectomy for breast cancer was in the 1980s.
Thanks for the commentary.. radiation has improved and has overtaken RP as a option in the low risk population. What is your take on proton and focal therapies.
RT is an option for all risk classes, not just low-risk. In my opinion it is the current no-brainer: noninvasive, optimal overall survival, outpatient treatment with minimal side effects. The most common side effect, rectal bleeding, can usually be limited to a very minor ailment controllable with suppositories. A lot better than permanent incontinence, the main drawback of RP. If you have the money or your insurance will pay for it, always choose proton over X-ray (IMRT). I‘ve had both, and the difference subjectively is striking: you have no radiation fatigue with proton, since the absorption of radiation in healthy tissue is reduced by 70%. The only treatment for high-risk PC that has been shown to be significantly better in terms of OS is the combination IMRT and brachytherapy (JAMA 2018), which was widely practiced in the US (think Rudi Giuliani anno 2000) but has declined in popularity recently, probably because just doing IMRT is simpler and higher doses can now be safely given. If you must have IMRT, find a center with concurrent MRI image guidance (so-called MR-Linac).
I can‘t say much about focal therapies except photodynamic, which is now increasingly being offered for low-risk PC. I think the clinical evidence is still thin (but see https://doi.org/10.1016%2Fj.prnil.2018.12.002).
The logic of these patients is silly. If you‘re worried that a biopsy will spread cancer, than you should be even more worried that surgery will (and there are real reasons for believing that!). Or that surgery leaves malignant cells behind on the resection borders.
Logically, these paranoid patients should be opting for AS or RT, not surgery. It‘s irresponsible of their urologists to support their delusions.
Absolute insanity - we should be heaping scorn on every urologist recommending either the 12-core biopsy or robotic prostatectomy.
> the risky and grossly unscientific biopsy samples blindly and randomly just 0.1% of the prostate.
> the robotic prostatectomy was FDA approved without any supporting evidence for safety and benefits.
> there is no irrefutable and reproducible scientific evidence that shows that robotic prostatectomy saves significant numbers of lives - we do have plenty of evidence of its many potential complications.
Amazing eh? Seeing insanity going full circle? H H Young’s first patient went to surgery based only on the feel of his prostate.
If a uro has a patient with a Gleason 6, is it ethical to treat if only because the patient wants to because of anxiety? Is this comparable to skipping a biopsy? Not calling for forced AS. Just wondering if the uros don't see an irony here.
Thanks, Rick. Not sure if you mean small practices in the community or large private practices. I understand that just by sheer numbers it is likely that large private practices may do most AS. Doctors but also patients and patient families play a role in that 40% number. Anxiety and depression need to be addressed head on. It's hard for some to accept that they can co-exist with a "cancer," even a low-grade one. like Gleason 6.
The elephant in the US community medical office is financial conflict of interest!
Beyond the broad 'ethics' reference, it is not named per se.
As advocates, we must repeatedly remind community urologists and radiation oncologists treating prostate cancer that we are on to them. It is not just about amortizing their very expensive equipment and paying their bills.
The more we as patient advocates remind practitioners, and the more patients question why a procedure is necessary, the more likely we'll drop that 40% rate to 4%.
In a general sense, all of this has to do with a lack of understanding about prostate cancer. Education about PCa should ideally begin in the primary care physician's office where there should be adequate information concerning the PSA that your PCP recommends. And then there, and not only in the urologist's office, information concerning PCa should be available. Etc., etc.
Good point.
After reading the European Urology article, the main reason these patients are opting for treatment without biopsy is avoiding biopsy morbidities, not “seeding“ of cancer. Given that the sensitivity and specificity of combined mpMRI and PSMA-PET/CT is so high (pratically 100%), skipping biopsy seems reasonable, but only if you opt for RP. To justify AS, you still need a Gleason value from a biopsy. As for RT, the Gleason value is traditionally used to decide if neoadjuvant ADT is necessary, but the study by Yang et al. (European Urology, 2019) casts doubt on whether ADT is useful at all in combination with RT for high-risk PC, and perhaps even counterproductive. If you accept their argument, then biopsy could also be skipped if high-quality mpMRI and PSMA-PET/CT results were available and the PSA also pointed to high-risk PC (PSA>20).
So the only justification remaining for biopsy would be avoiding treatment at all and opting for AS.
The question still remains why anyone is still opting for RP, a clearly inferior treatment. Just avoiding biopsy is not a sufficient reason.
Thanks for the additional comment. When I spoke with the surgeon, he emphasized patients fear of seeding. He said they also we were not candidates for AS.
As to moribidities ... like sepsis? --The German doc said they weren't a concern. He said a transperineal biopsy would not have satisfied these patients.
The article does mention tumor seeding among other issues:
“ Several benefits are arguable: no further complications after biopsies, reduced time from diagnosis to treatment, lower psychological burden, and anxiety in patients (ie, anxiety about biopsy-associated pain/complications and tumor seeding), and lower health economic costs (cost of additional PSMA-PET vs cost of unnecessary biopsies).“
These other issues do strike me as legitimate concerns. If one could do away with biopsies, all the better. However, this should not be made into an argument for RP and against AS or RT. In fact, in my humble opinion RP should long ago have been rejected as an inferior treatment just as radical mastectomy for breast cancer was in the 1980s.
Thanks for the commentary.. radiation has improved and has overtaken RP as a option in the low risk population. What is your take on proton and focal therapies.
RT is an option for all risk classes, not just low-risk. In my opinion it is the current no-brainer: noninvasive, optimal overall survival, outpatient treatment with minimal side effects. The most common side effect, rectal bleeding, can usually be limited to a very minor ailment controllable with suppositories. A lot better than permanent incontinence, the main drawback of RP. If you have the money or your insurance will pay for it, always choose proton over X-ray (IMRT). I‘ve had both, and the difference subjectively is striking: you have no radiation fatigue with proton, since the absorption of radiation in healthy tissue is reduced by 70%. The only treatment for high-risk PC that has been shown to be significantly better in terms of OS is the combination IMRT and brachytherapy (JAMA 2018), which was widely practiced in the US (think Rudi Giuliani anno 2000) but has declined in popularity recently, probably because just doing IMRT is simpler and higher doses can now be safely given. If you must have IMRT, find a center with concurrent MRI image guidance (so-called MR-Linac).
I can‘t say much about focal therapies except photodynamic, which is now increasingly being offered for low-risk PC. I think the clinical evidence is still thin (but see https://doi.org/10.1016%2Fj.prnil.2018.12.002).
The logic of these patients is silly. If you‘re worried that a biopsy will spread cancer, than you should be even more worried that surgery will (and there are real reasons for believing that!). Or that surgery leaves malignant cells behind on the resection borders.
Logically, these paranoid patients should be opting for AS or RT, not surgery. It‘s irresponsible of their urologists to support their delusions.
Absolute insanity - we should be heaping scorn on every urologist recommending either the 12-core biopsy or robotic prostatectomy.
> the risky and grossly unscientific biopsy samples blindly and randomly just 0.1% of the prostate.
> the robotic prostatectomy was FDA approved without any supporting evidence for safety and benefits.
> there is no irrefutable and reproducible scientific evidence that shows that robotic prostatectomy saves significant numbers of lives - we do have plenty of evidence of its many potential complications.
Amazing eh? Seeing insanity going full circle? H H Young’s first patient went to surgery based only on the feel of his prostate.
If a uro has a patient with a Gleason 6, is it ethical to treat if only because the patient wants to because of anxiety? Is this comparable to skipping a biopsy? Not calling for forced AS. Just wondering if the uros don't see an irony here.