Good news: More men with GG 1 prostate cancer decline surgery to pursue Active Surveillance
Also below: Bad News and New News
By Howard Wolinsky
A new study on prostate cancer presented at the American Urological Association annual meeting this week shows a dramatic decline in the past 15 years of men with low-risk prostate cancer opting for radical prostatectomies.
A large prostate cancer research study of two major patient registries—Surveillance,Epidemiology, and End Results (SEER) and Michigan Urological Surgery Improvement Collaborative (MUSIC)—discovered that from 2010-2024 the proportion of patients found in post-prostatectomy biopsies to have Gleason 6/Grade Group 1 had declined five-fold.
This means men are avoiding unnecessary prostate surgery and the risks of impotence and incontinence.
The paper appeared in JAMA Oncology and was presented this week at the annual meeting of the American Urological Association in Las Vegas.
The cohort study included 185,928 patients who underwent radical prostatectomies from 2010 through 2024. Researchers compared the proportion of Gleason 6 patients found in a population of 185,928 patients who had undergone radical prostatectomies.
The proportion of radical prostatectomies resulting in GG1 on final pathology reports decreased from 32.4% (5852 of 18,071) to 7.8% (978 of 12,500) between 2010 and 2020 in SEER and from 20.7% (83 of 401) to 2.7% (32 of 1192) between 2012 and 2024 in MUSIC.
Also: From 2010 to 2020, the prostatectomy rates changed from 43.7% to 48.5% for Grade Group 2 disease, 14.3% to 25.6% for Grade Group 3 disease, 4.3% to 6.2% for Grade Group 4 disease, and 5.3% to 11.9% for Grade Group 5 disease.
“These findings suggest that management of low-risk prostate cancer has improved during the past two decades, with a substantial decrease in the frequency of pathologic Grade Group 1 prostatectomies,” said lead author Steven Moda, MD, a urology professpr at the University of Michigan (Go Blue!) and his colleagues.
(Steven Monda, MD)
“We’re seeing progress at the local practice, statewide and national levels. These results align with other studies that showed increased use of active surveillance for low-risk prostate cancer since 2010,” Monda said.
“The decrease in the number of surgeries for low-grade prostate cancer shows that active surveillance helps.”
Kevin Ginsburg, MD, one of the co-authors of the study, assistant professor of urology at Wayne State University School of Medicine and co-director of the MUSIC prostate program, told me that multiple factors played a role in the reduction of the number of men found in post-surgical biopsies to have GG1:
“—Increased use of MRI before and after biopsy: Doing less biopsies for men with GG1 disease. Finding more GG2 disease. So overall the population of GG1 disease has decreased.
“—Increased use of AS. I suspect this is a big driver. Increasing comfort with AS for GG1 disease, taking less men with GG1 to surgery, so ultimately less final pathology is GG1 disease.”
Monda said: “We’re seeing progress at the local practice, statewide and national levels.”
Response to the study
Christian Pavlovich, MD, head of the Active Surveillance program at Johns Hopkins University, said: “These trends are expected and good to see. Less treatment of GG1 prostate cancer. Urologists are trying to do the right thing. But some GG1 patients still merit treatmentespecially if the concern for occult more aggressive disease (high PSA density or adverse MRI or high genomic score) or if the development of more aggressive disease over time (young patient, high volume) are concerns.”
Peter Carroll, MD, MPH, one of the pioneers of Active Surveillance in the 1990s, said the switch to surveillance was influenced by two factors: Greater uptake of AS and urologists starting not to biopsy based on PSA alone but increasingly used secondary serum and urine biomarkers (i.e., 4K, etc.) and MRI before biopsy to better determine who was at risk of higher-grade disease and selectively biopsy those patients.
“Detection rates of GG1 or unnecessary biopsy rates decreased. Both very good things,” he said.
Uropathologist Dr. Jonathan Epstein, of Advanced Uropathology of New York, said: “This study of two very large prostate cancer patient cohorts demonstrates that grade group1 prostate cancer in more recent times is being less frequently treated by radical prostatectomy. Although some of these patients could instead have selected radiation therapy, it is more likely that the results are due to more of these men selecting active surveillance.
“Also, the number of radical prostatectomies with biopsy grade group 1 decreased over the last 12-14 years from 47.5% to 14.1% in one cohort and from 24.7% to 8.3% in the other cohort.
“What this biopsy data shows is how critical an accurate reading of the biopsy grade is by the pathologist; if it is read as grade group 1 (Gleason score 3+3=6), the vast majority of men will not undergo radical prostatectomy. The study also found that approximately 8% of biopsy grade group 2 were downgraded to grade group 1 on prostatectomy, most likely as a result of overgrading the biopsy potentially leading to over treatment, further emphasizing the paramount importance of accurate biopsy grading.”
And what role do ASPI and AnCan’s virtual support groups and patient advocates play in this shift toward AS and away from radical prostatectomy?
Lead author Monda said: “I think a very large role. Men like yourself and others, who have shared their experience with Active urveillance, have likely greatly improved confidence in taking this approach to prostate cancer management. Medical literature has many obstacles to accessing it, includS\ing pay-walls and cumbersome jargon, directly reaching patients via advocacy or support groups gives another avenue for patient’s to gain insight and information outside of their doctor’s visit.”
And Rick Davis, co-founder of AnCan, which runs virtual support groups for men on AS and men with low- to favorable intermediate-risk prostate cancer, suggested that peer support groups and patient advocacy gave AS a boost, too.
He told his support group “mods” in an e-mail entitled, “You’re saving prostates, Ladies and Gents,’ said: “Groups like ours as well as the tremendous advocacy from individuals like HW are making an impact. Pat yourselves on the back - it's down to you making the men we speak to become their own best advocate and challenge their uros.”
Bad news: Misinformation in prostate cancer and myths are common in social media coverage
By Howard Wolinsky
Have you heard that prostate cancer can be passed on sexually? Or that urinary symptoms such as frequent urination are warnings for early prostate cancer?
Untrue. And untrue. But maybe you have run across these prostate cancer myths in social media?
Stacy Loeb, MD, a urology professor at NYU, told the American Urological Association annual meeting that her research on prostate cancer misinformation shows that prostatecancer myths are common across social media—especially TikTok—and span causes, symptoms, screening, treatment, and transmission of PCa.
Her team reviewed posts on YouTube, Instagram, and TikTok, and interviewed health care professionals about common prostate cancer myths. They found widespread misinformation, ranging from false symptoms and outdated screening guidelines to myths about treatment and transmission.
TikTok had the highest volume of misleading content. Loeb emphasized the need for clinicians to listen to patient concerns, offer vetted information, and provide information prescriptions to guide patients to reliable sources.
She also highlighted the crucial role of professional societies in curating accurate, up-to-date educational materials.
“[Prostate cancer misinformation] is widespread across online platforms and spans many different aspects of the disease. This can lead to real consequences, such as unrealistic expectations, delayed or missed screening, or even financial harm from spending on unproven treatments,” Loeb said in an interview with Targeted Oncology.
(Stacy Loeb, MD)
Loeb said: “Some of the most common kinds of misinformation actually span the entire spectrum of prostate cancer—everything from causes and symptoms to myths aboutscreening, treatment, supplements, and even the sexual transmission of cancer, which is not accurate. Prostate cancer is not sexually transmitted. So, we’re seeing myths across the entire disease continuum.”
Loeb said: “One of the common things we see is a lot of posts discussing early warning signs of prostate cancer as being bone pain, blood in the urine, or waking up at night to urinate.
“These are not early warning signs. It’s well established that prostate cancer is asymptomatic in its early stages. That’s actually why screening is so important—it doesn’t have symptoms until it’s advanced.”
“For example, bone pain would mean the cancer has already spread to the bones, which indicates advanced disease. So, it’s concerning when this type of misinformation spreads. Someone might think, ‘I don’t have any symptoms, so I’m fine,’ and skip screening, which is dangerous. On the flip side, people may become unnecessarily worried. Waking up at night to urinate is a common symptom of benign prostate enlargement, which affects most men as they age. So, assuming it’s cancer can cause undue fear.”
She said another issue is outdated information.
For instance, back in 2011 and 2012, the US Preventive Services Task Force recommended against prostate cancer screening. But that has changed—they now recommend shared decision-making. Loeb said: “However, many posts still circulate the old recommendations, which may mislead people into thinking screening isn’t recommended, when in fact, it is.”
BTW, TikTok and YouTube are not the only sources of bum information. I have reported on misinformation and myths on prostate cancer not only in mainstream media, but even medical guidelines. Check out my stories: in Undark and The Active Surveillor.
New news: Don’t miss The Active Surveillor’s free webinar with urologist Dr. Jonathan Epstein on May 17
The Active Surveillor is featuring famed uropathologist. Jonatham Epstein, MD, in a webinar entitled, “What you need to know about your prostate biopsy—the new news”
Dr. Jonathan Epstein with Howard Wolinsky, editor, The Active Surveillor
Saturday, May 17 at Noon - 1:30 pm Eastern.
Register here
Hosted by The Active Surveillor with ASPI and AnCan Foundation
The program will focus on men on early Active Surveillance but also consider those contemplating or doing radiation therapy or surgery.
Epstein recently launched Advanced Uropathology of New York after nearly 40 years on the faculty at Johns Hopkins University School of Medicine..
If you have questions for Dr. Epstein, please send them to howard.wolinsky@gmail.com
This month in my other blog “Prostate Cores: “Kidney stones/gallstones linked with prostate cancer?” Click here.
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I had wondered about this, thanks for the data. Also, the sad amount of nonsense posted to FB groups is...well, scary.
When Epstein said "Although some of these patients could instead have selected radiation therapy, it is more likely that the results are due to more of these men selecting active surveillance." I thought of all the 'stories' I have seen on FB where post radiation the results are perfectly clear of metastasis and low PSA for years following the procedure, one wonders if it is because GG1 was radiated. Of course, that doesn't save the, let's use victim, from the side effects of the radiation.