(Editor’s note: I wrote about the case of Dr. Francis Collins and his rapidly advancing prostate cancer in my blog in MedPageToday: https://www.medpagetoday.com/special-reports/apatientsjourney/109711?trw=no But I have more to say here.) By Howard Wolinsky
If no patient with low-risk prostate cancer on AS ever progressed to higher risk, there would be no point in AS — patients with low-risk PCa could just go home and never get examined again. Thus I don’t understand what the excitement is about in the Collins case. Some patients on AS will always progress and move to treatment. The point of AS is to postpone this as long as possible, and with high probability, for ever, but hopefully catch the progression in time. This seems to be Collins’ case—his PCa is still local, PSA 20 and Gleason 9, thus eminently treatable.
The real scandal is why such a knowledgeable physician like Collins would elect for radical prostatectomy. This has no medical benefits over radiation therapy for a man of his age, but substantially higher risks: incontinence (20% vs 2%), impotence (90%. vs. 50%), surgical complications that can be life threatening like Sect. of Defense Lloyd Austin recently experienced (two rounds in the ICU for internal urinary leakage and resulting sepsis).
Radiation therapy is a no brainer, and radical prostatectomy should be discarded (or even prohibited) except possibly for very young men who run some risk of secondary cancers from radiation therapy. And even those risks can be substantially reduced with proton therapy or brachytherapy instead of external beam IMRT (X-ray based).
In order to avoid a case li9ke Collin' becomi9ng an overwhelming argument against AS, I think it is incumbent upon urologists to advise ALL their patients appropriately, even between scheduled appointments. I would also argue that this is something that PCPs have to be sensitive to, and advise their patients--at least the ones who have been diagnosed with PCa--to consider the case as an outlier in the world of AS. Without this kind of follow-up, given the rather too common reaction to any diagnosis of cancer, this situation promises to have a negative impact on many men on AS and on many newly diagnosed men. And while you are doing a great job with 'The Active Surveillor,' I suspect the audience is made up primarily of individuals who are already savvy about PCa, or who have taken the initiative to become knowledgeable. Allan Greenberg
a little confused --- he was on AS, but the point of AS is to watch for something more ominous, which unfortunately happened here, so AS might not be the right option going forward (of course it still may be right but that's up to Collins)... so what is/has he doing wrong? thanks, sorry if missing your point
Good piece, Howard. Per usual. I turned 70 late last year and am a few months shy of my 6th anniversary on AS. By and large I don't worry, but I must say that reading about Collins does tick the fear up slightly, even though I realize it's truly a black swan event.
Bottom line is that I trust my urologist and continue to pay careful attention. Must admit I'm a little concerned since my last biopsy was Nov. 2020 and my last MRI the May before that. But since my PSAs remain low I'm not getting overly excited.
If no patient with low-risk prostate cancer on AS ever progressed to higher risk, there would be no point in AS — patients with low-risk PCa could just go home and never get examined again. Thus I don’t understand what the excitement is about in the Collins case. Some patients on AS will always progress and move to treatment. The point of AS is to postpone this as long as possible, and with high probability, for ever, but hopefully catch the progression in time. This seems to be Collins’ case—his PCa is still local, PSA 20 and Gleason 9, thus eminently treatable.
The real scandal is why such a knowledgeable physician like Collins would elect for radical prostatectomy. This has no medical benefits over radiation therapy for a man of his age, but substantially higher risks: incontinence (20% vs 2%), impotence (90%. vs. 50%), surgical complications that can be life threatening like Sect. of Defense Lloyd Austin recently experienced (two rounds in the ICU for internal urinary leakage and resulting sepsis).
Radiation therapy is a no brainer, and radical prostatectomy should be discarded (or even prohibited) except possibly for very young men who run some risk of secondary cancers from radiation therapy. And even those risks can be substantially reduced with proton therapy or brachytherapy instead of external beam IMRT (X-ray based).
In order to avoid a case li9ke Collin' becomi9ng an overwhelming argument against AS, I think it is incumbent upon urologists to advise ALL their patients appropriately, even between scheduled appointments. I would also argue that this is something that PCPs have to be sensitive to, and advise their patients--at least the ones who have been diagnosed with PCa--to consider the case as an outlier in the world of AS. Without this kind of follow-up, given the rather too common reaction to any diagnosis of cancer, this situation promises to have a negative impact on many men on AS and on many newly diagnosed men. And while you are doing a great job with 'The Active Surveillor,' I suspect the audience is made up primarily of individuals who are already savvy about PCa, or who have taken the initiative to become knowledgeable. Allan Greenberg
a little confused --- he was on AS, but the point of AS is to watch for something more ominous, which unfortunately happened here, so AS might not be the right option going forward (of course it still may be right but that's up to Collins)... so what is/has he doing wrong? thanks, sorry if missing your point
Good piece, Howard. Per usual. I turned 70 late last year and am a few months shy of my 6th anniversary on AS. By and large I don't worry, but I must say that reading about Collins does tick the fear up slightly, even though I realize it's truly a black swan event.
Bottom line is that I trust my urologist and continue to pay careful attention. Must admit I'm a little concerned since my last biopsy was Nov. 2020 and my last MRI the May before that. But since my PSAs remain low I'm not getting overly excited.