New study confirms AS uptake in United States growing, but TAS says it still 'sucks the big one'
Yet another 'shit sandwich' in prostate cancer care
By Howard Wolinsky
A new report from Harvard researchers confirms what the American Urological Association told us in 2022—Active Surveillance (AS), close monitoring of lower-risk prostate cancer, is on the rise in the United States.
Technically, the Harvard researchers didn’t only look at AS. They lumped it in with two other related non-treatment approaches: watchful waiting and “no treatment.” Close enough. They call this category “expectant management.”
Sounds like having a baby, no? But it’s about having a lower-risk cancer with which you can co-exist.
I asked the researchers for a breakdown of AS and the other approaches. I haven’t heard back. I’ll let you know if I do.
Edoardo Beatrici, MD, et al. report in the December issue of European Urology that in 2020, roughly 60% of men with low-risk prostate cancer go on AS. But flip it. That means roughly 40% don’t go on AS though they are candidates.
Two words in the opinion of TheActiveSurveillor.com: That sucks. And I’ll add: The big one.
Or as my favorite biostatistics guru, Andrew Vickers, PhD, of Memorial Sloan Kettering Cancer Center, put it in the former Twitter: What a disaster.
The Harvard researchers used the U.S. National Cancer Data Base (NCDB), a nationwide oncology registry of more than 1, 500 US Commission on Cancer–accredited hospitals reporting more than 55% of all newly diagnosed PCa cases in the United States.
They compared growth in expectant management between 2010 and 2020. Their analytical cohort included 754,949 U.S. men diagnosed with localized PCa between 2010 and 2020
Back in 2010, when I was diagnosed with a single core of Gleason 6, a urologist couldn’t wait to get me into his OR to “cure” my cancer. He didn’t support AS.
It was the Wild West in Prostate Cancerland. Shoot with a rising PSA, biopsy, operate, and ask questions later. I had to fight—or get a second opinion— to go on AS, which, more or less, I am still on today, 13 years later.
I was told in December 2010 that maybe 6-10% of men like me went on AS. The Harvard group found in 2010 there was a higher proportion of men on expectant management, a broader category.
The researchers said expectant management increased from 13.7% in 2010 to 64.4% in 2020 for men with low-risk PCa.
AUA had its own AQUA database. But the numbers are about the same.
No doubt, things have changed for the better.
The researchers put it well when they said: “The management of prostate cancer has evolved from a paradigm of ‘treat when caught early’ to ‘treat only when necessary.’
Still, things could be much better. The USA lags overall from the 90%+ uptake of AS in the state of Michigan, Sweden, and the United Kingdom.
I taught medical journalism for about a decade in the graduate program at the storied Medill School of Journalism at Northwestern University in Chicago.
One of my students introduced me to the concept of a “shit sandwich.” She said every time she approached me I winced. I think she was right. She said I was too straightforward and needed to blunt my criticism of her work with a “shit sandwich.”
Say something nice. Deliver the criticism. Leave on a positive note.
OK, I am sharing the Harvard report as a shit sandwich.
I made a positive point about the increase in acceptance of AS to make everything palatable with a nice slice of bread.
Then I gave it some context": The “news” (or “shit”) showing how the USA is lagging in AS.
So I’ll end with another slice of bread.
The Harvard group expects things to continue on the upswing: “The frequency of expectant management for low-risk PCa has increased dramatically during the past decade. We expect this trend to further increase owing to the growing awareness of the harms of overtreatment of indolent disease.”
(Harms include erectile dysfunction and incontinence caused by aggressive treatment.)
“We found that the proportion of men receiving expectant management for low-risk prostate cancer is increasing. We conclude that growing awareness of the harms of overtreatment has profoundly affected trends for prostate cancer treatment in the USA.”
More sandwiches in PCa
By Howard Wolinsky
Unfortunately, as we head into 2024, many areas in prostate cancer care fit the bad news category in the U.S., including lack of screening for emotional distress and slow acceptance of safer transperineal biopsies.
A leading urologist told me in an unrelated interview last week that expectations for AS are being met in major metro areas like Chicago, LA, San Francisco, and New York. She said in her practice, 90% of low-risk patients go on AS, usually as a means to delay more aggressive treatment.
But she said this typically is not true in states with large rural areas. She said AS may not be practiced in these areas, pathologists may be unskilled in urogenital pathology, radiologists unpracticed in reading prostate MRIs, and urologists not up to snuff.
There are growing shortages of urologists in rural areas and also inner-city areas. And then there’s the issue of whether Black men are being offered AS.
A few years ago, I made a list of personal to-dos to make AS more widely available.
Is Santa, MD, listening?
Consider this as what is wrong with many trials and clinical studies-- we can't get some very basic and important data. I'm not sure I'm saying this correctly, but some of the basic building blocks are just as important as the bow wrapped final 3 sentences. Also consider the number of older, retirering dotors that are giving more space for younger and better informed doctors. These doctors traditionally know much about AS, and seeningly are more likely to try something different. kapm
Changing old habits is surprisingly hard for doctors.
Specialists may be some of the worst examples because, for many of them, their income is largely based on procedures. There may be a financially-based bias for some urologists not wanting to change their ways with AS (especially as it seems in rural areas) because, after all, they are surgeons.