Is Active Surveillance for low-risk prostate cancer on its way out?
Experts suggest a new focus for AS with favorable intermediate-risk
Back in February 2017, I was the first patient to speak at the American Society of Clinical Oncologists Genitourinary (GU) Cancers Symposium.
(Read my account of how I was overlooked at the meeting and ended up ranting before 3,000 cancer docs and health professionals: https://www.medpagetoday.com/hematologyoncology/prostatecancer/63251
I met the bigwigs in the GU area. I chatted afterward with British urologist Freddie Hamdy, MBChB, of the University of Oxford. He revealed a new way to prostate cancer and active surveillance. He spoke about active surveillance (AS) being only a step along the evolutionary development of management of low-risk Gleason 3+3 “cancer.”
(Dr. Freddie Hamdy, of the University of Oxford)
He foresaw the day in the not-so-distant future when AS would only be used to manage patients with favorable intermediate-risk Gleason 3+4=7 prostate cancer. Patients like me, with low-risk Gleason 6 “cancer,” would take a pass on the whole ritual and rigamarole of AS and would avoid all or most of the urology visits, PSAs, MRIs, and biopsies.
Those of us with low- or very low-risk lesions tend to think of ourselves as being on a non-interventional path. Yet, this approach is highly medicalized--with all the needle pokes as part of transrectal ultrasound (TRUS) or transperineal biopsies and risks from TRUS for potentially deadly sepsis and other infections. MpMRIs were just being phased in 2010 when I was diagnosed.
We faced a considerable amount of poking and prodding. I had annual biopsies in those days. As it stands now, I haven’t had a biopsy in about six years.
(Judd Moul, MD)
Judd Moul, MD, a urologic oncologist at Duke University in Durham, North Carolina, gave me pause and potentially a glimpse at the future of AS at an AnCan/UsToo Virtual Support Group a few years ago when he told me: “Just to play devil’s advocate. In my opinion, you should have never had that [first] biopsy. You probably would have never known anything was wrong with you, and you wouldn’t have 10 years of concern about this.” (Video of Moul at AnCan:
He had a point, an important one. He was talking about future generations, not those like mine who had already lost their biopsy virginity and had been diagnosed with prostate “cancer lite,” with many (45%) still being like lambs into the operating rooms and radiotherapy suites for potentially harmful side effects, such as impotence, penis shortening, loss of libido, and urinary and fecal incontinence.
Management of prostate cancer even with active surveillance is no garden party with all the biopsies, digital rectal exams, and mpMRIs, and anxiety that patients on AS face.
I once got into a shouting match with a guy with advanced prostate who asked me: “Why don’t you guys on AS put on your big boy pants and have your biopsies?”
He didn’t understand that biopsies are the mountains patients on AS face. They seem like small things to those who have undergone surgery, radiation therapy, and hormonal treatments and encountered the nasty after-effects mentioned above as well as hot flashes and “chemo brain.” Biopsies are mountain enough for the low-risk majority.
(E. David Crawford, MD)
Recently, E. David Crawford, MD, a urologist and long-time researcher on prostate cancer, told me in an interview that the point of PSA testing ought not to be finding patients suitable for AS.
Rather, he argued that PSA testing should be used to determine which patients do not need PSA testing. He said PSA can be combined with molecular testing to find patients who can avoid biopsies. Follow-up PSA testing can be spaced out in five- to 10-year intervals, just like colonoscopies.
I will be reporting on this in my column in MedPageToday.com. I’ll send out more when the column comes out.
The bottom line is that change is in the wind, and patientswith low-risk prostate cancer will be able to avoid those biopsy mountains.
[Part II Next: A new kind of PSA test that can be used to rule out biopsies and even mpMRIs.]
Don’t miss this program: Top docs—including Dr. Laurence Klotz, who named AS; Dr. Peter Carroll and Dr. Peter Albertsen, who helped develop the approach, and Dr. E. David Crawford, who believes it’s time to move beyond AS— will be exploring the future of Active Surveillance at 11 a.m. Eastern April 22. Register here ASAP: https://zoom.us/meeting/register/tJEtfuuqrzwtHNPuqzkigx65YBk8vV-teUdy