Thanks for your comments, Dr. Walser. I appreciated your terminology with "focal therapists" and "magnetic surveillance." Do you think there should be an age cut-off on AS--say at age 75--depending on history and overall health? HW
As a provider who sees many many of these patients, I agree with the comment that several practitioners are riding the fear of low risk prostate cancer and promoting expensive focal therapies which result in the same long-term cure as doing nothing. Unfortunately, many such prostate "centers" cannot take medicare payments for anything--including MRI exams, ultrasounds, PSA testing, etc since these physicians have largely "opted out" of CMS plans. A prostate "Focal" therapist should have the billing support to authorize payments for these procedures (as possible), should maintain a database and follow their recurrence and complication rates, and should limit focal treatments to significant lesions after consultation with the patient and his partner.
I agree that most Gleason 6 cancers should be left alone and we monitor most of these patients who have such lesions with "magnetic surveillance" which is periodic PSA checks and yearly to every-other yearly MRI exams. Most of these lesions found by blind biopsy are MRI-invisible and we monitor them to make sure they stay that way in the face of stable PSA values.
One caveat here is that Gleason 6 biopsies obtained from "blind" office biopsy will miss lesions in front of the prostate or way back towards the base. I have many patients with high PSA levels who have a blind biopsy for gleason 6 but have an obvious cancer by MRI which we target biopsy and discover Gleason 7 or higher. Active surveillance or magnetic surveillance for prostate cancer requires MRI imaging to rule out these lesions missed with non-targeted biopsy. I have seen several patients with rising PSA levels and 6 or 7 years of annual negative or low-risk biopsies who have an obvious prostate cancer on MRI located in those difficult locations.
Sure thing.
Thanks for your comments, Dr. Walser. I appreciated your terminology with "focal therapists" and "magnetic surveillance." Do you think there should be an age cut-off on AS--say at age 75--depending on history and overall health? HW
I think we should stop AS and PSA testing at 80. Many 75 year olds today are pretty healthy and vibrant and have many years to enjoy!
Dr. W. Could you contact me at
howard.wolinsky@gmail.com
I have some questions
As a provider who sees many many of these patients, I agree with the comment that several practitioners are riding the fear of low risk prostate cancer and promoting expensive focal therapies which result in the same long-term cure as doing nothing. Unfortunately, many such prostate "centers" cannot take medicare payments for anything--including MRI exams, ultrasounds, PSA testing, etc since these physicians have largely "opted out" of CMS plans. A prostate "Focal" therapist should have the billing support to authorize payments for these procedures (as possible), should maintain a database and follow their recurrence and complication rates, and should limit focal treatments to significant lesions after consultation with the patient and his partner.
I agree that most Gleason 6 cancers should be left alone and we monitor most of these patients who have such lesions with "magnetic surveillance" which is periodic PSA checks and yearly to every-other yearly MRI exams. Most of these lesions found by blind biopsy are MRI-invisible and we monitor them to make sure they stay that way in the face of stable PSA values.
One caveat here is that Gleason 6 biopsies obtained from "blind" office biopsy will miss lesions in front of the prostate or way back towards the base. I have many patients with high PSA levels who have a blind biopsy for gleason 6 but have an obvious cancer by MRI which we target biopsy and discover Gleason 7 or higher. Active surveillance or magnetic surveillance for prostate cancer requires MRI imaging to rule out these lesions missed with non-targeted biopsy. I have seen several patients with rising PSA levels and 6 or 7 years of annual negative or low-risk biopsies who have an obvious prostate cancer on MRI located in those difficult locations.