Younger uros and academics favor AS

Some MD views on renaming Gleason 6 as a noncancer.

Is Active Surveillance (AS), close monitoring of low-risk (Gleason 6, or Grade Group 1) prostate really a success story?

Well, yes and no. Some men are being left behind, often deliberately, o their urologists, especially older ones, may not be fans of AS. So choose your doctor with care.

60% of U.S. patients with Gleason 6 prostate lesions go on AS, a dramatic increase from 2014—though still below the 94% rate in Sweden and 91% in Michigan.

Of course, that means 40% choose to be treated. It will never be 100% because of anxiety and basic opposition to the concept of AS.

Different strokes for different folks, right?

A new study in the April 26 issue of European Urology Focus reports that despite this progress, low-risk prostate cancer “remains overtreated. This suggests a disconnect between daily physician practice and the standard of care.” The researchers hypothesized that GG 1 disease “is overtreated because of common misconceptions regarding its true natural history.”

Dr. Ragheed Saoud, of Arthur Smith Institute of Urology, Northwell Health, Riverhead, New York, led a worldwide survey of physicians to better understand their approach to management of GG 1 PCa. A 17-question survey was sent to urology, radiation oncology, and pathology societies on six continents and was posted on Twitter. Among 1303 participants, 55% were urologists, 47% had completed fellowship, and 49% practice in an academic setting.

There were huge differences in views on AS.

724 (83%) of clinicians routinely recommend AS for GG 1 PCa and have never/rarely regretted it, while 18 (2%) “often” regretted it.

“Routine AS was more common among physicians aged less than 40 years, those in practice for less than 10 years, and those living in North America, Europe, or Australia/New Zealand.

Saoud collaborated with several doctors with whom I proposed a year ago that Gleason 6 go through an identity change and be renamed a noncancer. Drs. Scott Eggener, who has led the campaign to rename Gleason 6, Alejandro Berlin, Matthew Coopersburg, Gladell Paner, and Matthew Coopersburg were co-authors of this physician survey.

(Our articles appears here: https://ascopubs.org/doi/full/10.1200/JCO.22.00123?role=tab)

39% (428) supported a name change while 31% (340) opposed the idea and 323 (30%) were uncertain.

These findings are very close to a survey AnCan, Active SUrveillance Patients International, Prostate Cancer Support Canada and TheActiveSurveillor.com conducted among more than 450 AS and former AS patients:

The researchers found that among physicians: Those in support were more likely to be aged less than 40, in practice for less than five years, urologists, and fellows trained in urologic oncology. So consider these factors in choosing an AS physician.

You hear about “decisional reget” among patients, about 10% of whom are sorry they chose AS vs. other more aggressive treatments, or vice versa. (Actually, AS has a lowe regret rates.)

A few urologists feel regret, too. (They also can be carriers of anxiety.)

Clinicians who routinely recommend AS for GG 1 PCa rarely regret their decision. AS is most preferred by urologists and radiation oncologists, particularly those in North America, Australia/New Zealand, and Europe. Younger physicians and those with fellowship training are most likely to advocate for AS. A significant proportion of physicians still do not accept AS as the standard of care for management of LRPCa. There is a substantial minority of physicians with views regarding long-term

No surprise on this: opposition to AS was common among pathologists (61%). But other studies showed a 90% rejection rate among pathologists.

So maybe some change is happening i n pathologists?

The new names proposed to replace “cancer” for GG 1 are neoplasm of low malignant potential (51% approval), indolent neoplasm rarely requiring treatment (23%), and indolent lesion of epithelial origin (8%).

I know that Eggener, my former urologist, doesn’t expect an overnight change. He is playing the long game, which he describes as a “career goal.”

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Dr. Epstein’s video and Q&A

By Howard Wolinsky

Jonathan Epstein, MD, of Johns Hopkins, is an international pathology rockstar.

He drew about 650 registrants to his April 29 videos from Active Surveillance Patients International’s event. Many just wanted to view the videos later. More than 250 patients attended the meeting.

So ASPI’s Bill Manning posted the videos STAT.

Here is the video from Active Surveillance 101 in biopsies and second opinions along with a Q&A with Dr. E.: https://aspatients.org/meeting/as-101-episode-5-second-opinions-and-biopsies/

The ActiveSurveillor.com will report more soon.

The full AS 101 series is available at https://aspatients.org/meeting/second-opinions-and-biopsies/