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Latest Evidence on Active Surveillance Interventions
Prostate Cancer | Last Active: Aug 28 4:56am | Replies (57)Comment receiving replies
Your analysis of the evidence discussed in this review is spot on!
However, I think the review's conclusion comes across as overly negative and somewhat unwarranted:
"...With moderate certainty, exercise programs improve cardiorespiratory fitness and some patient-reported outcomes (quality of life, fatigue, cancer-related worry), supporting lifestyle change as structured supportive care during surveillance. With low to very low certainty, evidence does not show a consistent, reproducible reduction in key oncologic outcomes such as biopsy upgrading, MRI progression or durable deferral of definitive treatment....For men undergoing active surveillance, lifestyle interventions may be beneficial as supportive measures to improve physical well-being, selected patient-reported outcomes, and cardiometabolic health. However, current evidence remains insufficient to demonstrate a consistent effect on biopsy upgrading, MRI progression, or durable deferral of definitive treatment."
IMHO if I was just diagnosed with low or favorable risk PCa, this review's conclusion is probably going to dampen my resolve to implement any of the cited evidence based interventions. Why am I not surprised?
I think it's important to put these evidence based interventions alongside the alternative...active treatment.
For example, if one goes with the "gold standard" RALP treatment there's an 8 year biochemical reoccurrence (BCR) risk of 21% for Low Risk, 25% for Favorable Intermediate Risk, 41% for Unfavorable Intermediate Risk and 60% for High Risk PCa, in the post-2010 era.
https://www.sciencedirect.com/science/article/abs/pii/S1078143924003442
That doesn't sound anything like "certainty". It sounds more like RALP is quite likely to put my PCa into a "durable deferral of (additional) definitive treatment(s)"....not to mention the absolute certainty of short term, high likelihood of intermediate term and possibility of long term side effects.
In my case, I considered my FIR diagnosis a "draft card" into evidence based intervention "boot camp" and, in my opinion, it needs to be considered as such.
I fully understand why many looking at the ERASE protocol have a million reasons why they can't or won't participate...maybe even receiving medical advise not to even try...but at the end of the day these folks shouldn't kid themselves that going the active treatment route is going to definitively resolve anything...the evidence indicates they are simply trading off to a different set of likely issues.
I am not against active treatment; but the evidence is clear that this also provides "low to very low certainty" (using the conclusion criteria of this review’s authors) that it will be the last time one has to deal with the aftermath of their PCa.
Replies to "@paulsweeney Your analysis of the evidence discussed in this review is spot on! However, I think..."
@handera “…current evidence remains inconsistent to demonstrate a effect on biopsy grading, MRI, etc…”
Nothing works consistently on everyone - even definitive treatment fails 30% of the time for both radiation and surgery.
So why shouldn’t drastic -and they are for some people, as drastic as surgery - lifestyle changes ALSO fail 30% of the time?
Don’t get me wrong, if 70% of men could avoid treatment by doing as you have done, it would be Breaking news on CNN, but sadly it only works for some and for many others, only short term. Best,
Phil
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@handera Alan, this is really well put — and I think you've identified something important that the review itself doesn't address.
The review holds lifestyle interventions to the standard of "durable deferral of definitive treatment" and finds the evidence insufficient. Fair enough. But as you say, the same standard applied to RALP yields 21-60% biochemical recurrence at 8 years. That's not a cure — it's a deferral with side effects.
What strikes me is the asymmetry in how we evaluate the two approaches. Lifestyle interventions are expected to prove they prevent progression before they're taken seriously. Surgery is assumed to be definitive and the burden of proof falls on anyone who questions it. But the data you've cited shows that assumption doesn't hold — a significant proportion of men who undergo surgery will face further treatment down the line, plus the near-certainty of short-term side effects and the real probability of lasting ones.
I agree with the review's finding that exercise has the strongest evidence — the ERASE trial data on PSA, cancer cell growth, and quality of life is hard to argue with. And I think the review is right to be cautious about supplements as a category. But the conclusion that lifestyle interventions provide only "supportive" benefit while treatment provides "definitive" benefit doesn't survive contact with the recurrence data you've shared.
Your "boot camp" framing is exactly right. A diagnosis isn't a death sentence — it's a signal to get serious about everything within your control. And for low-to-favourable intermediate risk, the evidence increasingly supports that an active, engaged approach to surveillance is a legitimate strategy, not just a holding pattern.
Really glad you're in this conversation.
Paul