Latest Evidence on Active Surveillance Interventions

@heavyphil

Not sure where your 30% failure rate, for definitive treatment, comes from; but the 2024 research I cited earlier indicates that the BCR rate, 8 years post RALP, varies significantly, based on biopsy determined risk category, from 21% to 60%.

I’ve heard Dr. Matt Cooperberg (UCSF) indicate that if he has a Gleason 3+3 patient decide anything other than active surveillance, he feels he has not adequately informed him of the true nature of his disease.

IMHO, under the current way of labeling “prostate cancer”, it’s two different diseases…based on risk category, regarding its life threatening nature.

That’s why I think evidence based, patient controllable interventions, are primarily for managing “low risk” PCa men, defined either as being diagnosed with Gleason 3+3 or having a low risk Decipher score.

Higher risk PCa should be actively treated, even though additional treatment(s), down the road, is(are) more likely to be needed.

What I wonder is how many men with low risk PCa go forward with active treatment and then attribute their “remission” to the active treatment, when in fact they may have done just as well….possibly many more years without potential side effects….if they had no active treatment and/or had waited until higher risk disease had been confirmed.

@handera

A timely comment?

This study just published yesterday!!!

“Prostate Cancer Mortality After Relabeling Low-Grade Prostate Cancer as Precancerous”
https://jamanetwork.com/journals/jamaoncology/article-abstract/2849438
Conclusion:

“In this study, dropping the cancer label from GG1 prostate disease and redefining GG1 prostate disease as a precancerous lesion led to a net reduction in estimated prostate cancer deaths. Proponents for retaining the cancer label for GG1 prostate disease should argue relabeling would have close to zero effects on screening rates or that other harms outweigh the benefits of reduced prostate cancer mortality.”

Results: In the base case, which was relatively conservative, relabeling would lead to 6-fold more annual prostate deaths avoided than caused (2835 vs 452).

@handera My 30% comes from the Chairman of Urology of Northwell. I consulted with him early on and he told me that 30% of all surgical cases wind up needing retreatment, which is why my notion that surgery solved the problem was incorrect.
And since ‘outcomes’ overall are the same for surgery vs radiation, I assume the 30% failure rate applies to radiation as well.
I am not even considering the 3+3 category for either, since recurrence should be rare for either.
Phil

@handera Man, that study is REALLY bizarre!! So telling men that PSA screening is going to look for ‘precancerous’ conditions - and NOT label their GG1 as ‘cancer’ - is going to increase the number of men seeking screening and thereby avoid an increase in PCa deaths ( by men NOT wanting to be screened in order not to hear the word ‘cancer’); and by a 6 fold decrease in mortality at that?
That’s really reaching, IMO.
Let’s try this: I personally was diagnosed with bladder ‘cancer’ Grade 0, meaning not invasive into the muscle layer.
I had these lesions removed 3 times by two different surgeons and they all came up Grade 0; however, the fact that they kept coming back prompted my urologist to intervene with BCG/Interferon injected into the bladder to attempt to halt the process.
Knock wood, so far it has worked for almost 5 years and I am still alive.
When I questioned my doc about why I needed to worry, since the Grade 0 was the lowest form of cancer possible, he told me these lesions can change all the time and leapfrog from a Grade 0 to a Stage 4 rather quickly; dead in a year once that happens.
Having that word ‘cancer’ burned into my brain prompted me to keep up with my screening every 6 months, find new lesions while small snd treatable, and finally have treatment to hopefully eradicate it for good🤞.
Had I been told it was ‘precancerous’ and should be watched, I, as a health professional, would have continued screening, but How many less educated, less informed men would???
How many would view necessary periodic screening as a nuisance or a money grab by big medicine? I can almost hear, “Yeah, doc, LIFE is a precancerous condition…take care!”
So for me, this study is a real problem and I cannot imagine what AI engine or thought process came up with the conclusion that changing the words changes the facts. You can’t SPIN abnormal cells into something you WISH they were.
We now know so much more about overtreatment, AS, Decipher scores, genomic tests…there’s no need to change the words when all you have to do is change the protocol. Best,
Phil

@heavyphil

Well, this 2024 study of 6682 men, who underwent RP…3,492 (52%) and 3,190 (48%) before and after 2010, found a BCR rate of 21% increasing to 60% as biopsy pathology indicates a more aggressive cancer.

This trend of higher BCR potential, after RP, as ones biopsy pathology indicates higher aggressiveness is what I would expect.

A single 30% figure simply doesn’t address the broad spectrum of PCa aggressiveness found among the male population or a more personalized conclusion, based on the aggressiveness of an individual diagnosis.

@heavyphil

Appreciate your opinion, and understand your example.

However, before you dismiss this as “bizarre” you may not have considered these factors:

Drs. Andrew Vickers, of Memorial Sloan Kettering; Matthew Cooperberg, of UCSF; Christian Pavlovich, of Johns Hopkins; Peter Carroll, of UCSF, and Scott Eggener, UCLA, the authors of this study, are among the most influential and cutting edge physicians in the active surveillance field.

They are about as very far from “anti-treatment whack jobs” as one can get.

However, because of their vast experience with PCa patients they see what attempts to “PSA screen” every man has done within their own specialties…regarding the over treatment of scared, uninformed men.

I can think of only a couple other physicians who are so well known for their work in the active surveillance field.

It’s difficult for you and I to put ourselves back to when we knew little to nothing about the prostate; but these physicians see newbies everyday and there often emotional, even irrational, reactions when trying to come to grips with a “cancer” diagnosis.

Couple that initial ignorance with the fact that most have absolutely no symptoms whatsoever and these men are reluctant to justify any attempt to be “PSA screened” or they easily decide “I’ll think about that later…I feel just fine”.

The fact of the matter is that some of these “clueless” men DO indeed have clinically significant PCa and it should be treated (unfavorable risk and above) but they are in that “ignorance is bliss” state….until they are not.

It’s now well known among these physician experts in AS (whether you want to admit it or not) that true Gleason 3+3 “cancer” does not metastasize. Yes, men with that diagnosis sometimes progress to a more aggressive diagnosis, but that is because smaller, more aggressive tumors were simply missed in the original biopsy diagnosis.

What should one expect when only sampling ~2% of the prostate during a biopsy?

No one is “spinning” anything regarding terminology. These physician experts are clear that 3+3 cells are abnormal…so is HGPIN….

The point is that 3+3 does not metastasize AND that this is the key feature of what we, in our culture, call “cancer”.

Even the unformed equate the word “cancer” with uncontrollable cell growth, leading to death.

I am a researcher of 45 years, so I probably have a different perspective regarding scientific data…both its value and its limitations.

However, most folks I know don’t see it that way…they hear that they have “cancer” and immediately draw conclusions based on folks they know that died of their cancer.

I’ve seen so many comments from men that, because they heard the word “cancer” associated with their disease come to an absolutely irrational conclusion…”just cut it out of me”….not realizing that even if it truly is cancer with metastatic potential, that “cutting it out” is highly likely NOT to solve their problem…note BCR rates.

Anyway this study, now two days old, by the leading physician authorities in the field of AS is going to have a huge impact regarding the diagnosis and care of what today I’m still calling “low risk prostate cancer”.

I can’t wait until the medical profession finally sharpens its pencil and comes up with a phrase that truly captures the meaning of a LR PCa diagnosis.

@handera OK…so please lead me from Point A - the biopsy ( we did get that far, right?) to Point B:
“Sir, you have some PRE- cancerous lesions in your prostate which have to be followed by annual PSA tests and perhaps, additional biopsies”.
Now tell me how THAT statement will have a six fold decrease in cancer deaths over time?
IF this was a retrospective analysis of ‘harm done’ to men who have suffered from overzealous treatment, and a 6 fold decrease in THAT would be accomplished, I’d be All IN…but it is not.
And while 3+3 does not metastasize, AS is the preferred treatment; but where is it written that 3+3 will NEVER become 3+4 or higher? People forget the ACTIVE part of the equation: biopsies! And who hasn’t heard a man say he would rather have the cancer than get the biopsy?
Look, I am not looking to be ‘that guy’ - a stubborn contrarian who refuses to believe what is right before his very eyes - and I have zero argument with your position concerning exercise, diet, etc…none. It works for you, and that’s great.
But I am truly baffled by what this esteemed panel is trying to convey. Didn’t we learn the painful - and many times fatal - lessons of the 2012 debacle concerning PSA screening?? Why would they want to open the floodgates to that again? Sorry, but I just don’t get it at all…
Perhaps other members of the forum will weigh in with their thoughts; mine are my own and I am not averse to being trounced by public opinion and shown the errors in my way of thinking. Best,
Phil

@heavyphil

This subject is off this threads topic (sorry Paul) so I won’t post more about it here; but I’m more than willing to discuss further, if you want to start a new thread regarding this particular subject.

These expert physicians performed a modeling study of the impact of calling GG1 “precancerous”, rather than its current “cancer” label, for reasons I already articulated.

This relabel would result in two competing outcomes.

“One argument raised by critics is this would decrease adherence with essential monitoring (active surveillance) and therefore lead to increased prostate cancer mortality. However, relabeling GG1 prostate cancer also reduces overdiagnosis and overtreatment, and given that these are the major disincentives to prostate-specific antigen (PSA) screening, it should increase use of prostate cancer screening and thereby reduce deaths from prostate cancer.”

These authors agree with you…more extensive PSA screening saves lives AND they also are allowing the critics contention that relabeling GG1 will cause more men to abandon active surveillance, thereby increasing PCa specific mortality.

In there model’s base case, which was relatively conservative, relabeling would lead to a 6-fold increase in annual prostate deaths avoided over deaths caused by lack of AS adherence, due to wider PSA screening acceptance.

They also performed numerous model scenarios, modifying inputs, all of which failed to change the final net benefit conclusion.

Overdiagnosis and overtreatment are the major disincentives to prostate-specific antigen (PSA) screening, this disincentive DECREASES if GG1 were labeled as it truly is….a non metastasizing disease.

A man’s initial fears and concerns to rush into treatment are ameliorated if he is told his CURRENT disease is precancerous and will not metastasize; BUT he will still need to diligently monitor progression (AS recommended) to ensure a more aggressive form of the disease is not found at a future date.

@handera “relabeling GGI reduces overdiagnosis and overtreatment”…
…BY WHOM??
Urologists are specialists who should ALL be adhering to the current norms, which state that G3+3 and select 3+4 should be addressed by Active Surveillance. They already KNOW this.
However, if a doctor decides to go rogue and attempt to coerce patients into treatment, no change in wording is going to change that.
Case in point: I practiced dentistry for 42 years. Many, many patients have cheek biting issues - including myself. It stems from either a slight malpositioning of the teeth or an exaggerated chewing motion.
This causes a low-grade chronic injury, very similar to a callus forming on your hands; the tissue thickens from over usage. In time, some patients develop a whitish line that runs from the back of their inside cheek forward toward their mouth opening. This is called a Linea Alba.
It is totally innocuous and should be left alone – similar to a Gleason 3+3. Watch it, look for changes, but don’t do anything.
However, I had one particular oral surgeon to whom I referred patients, constantly frightening patients with the idea that this innocuous line in their mouths was going to turn into oral cancer. She would then get them in for ‘treatment’ which would consist of her scraping away the white line with the edge of a scalpel or using electrical cautery to remove it.
The patient would then return to my office and relate this harrowing tale. As diplomatically as I could, I would tell them that it was probably unnecessary and not to worry about it. Unbeknownst to me, the oral surgeon had already rescheduled the patient to return in six months to once again remove this harmless white line which by that time would have returned from constant chewing. She also sent the tissue out for a biopsy, which was another charge the patient incurred.
Finally, I spoke to the oral surgeon about this and she tried to bullshit me as well!
Needless to say, I stopped referring to her and found someone else. Yet, I am sure other unethical, rogue surgeons were doing similar things.
All I am trying to say here is that you can change the words all you want, but getting doctors to follow those words and allaying patients’ fears is quite something else. Best,
Phil

@heavyphil

This subject is off this threads topic (sorry Paul) so I won’t post more about it here; but I’m more than willing to discuss further, if you want to start a new thread regarding this particular subject.

These expert physicians performed a modeling study of the impact of calling GG1 “precancerous”, rather than its current “cancer” label, for reasons I already articulated.

This relabel would result in two competing outcomes.

“One argument raised by critics is this would decrease adherence with essential monitoring (active surveillance) and therefore lead to increased prostate cancer mortality. However, relabeling GG1 prostate cancer also reduces overdiagnosis and overtreatment, and given that these are the major disincentives to prostate-specific antigen (PSA) screening, it should increase use of prostate cancer screening and thereby reduce deaths from prostate cancer.”

These authors agree with you…more extensive PSA screening saves lives AND they also are allowing the critics contention that relabeling GG1 will cause more men to abandon active surveillance, thereby increasing PCa specific mortality.

In there model’s base case, which was relatively conservative, relabeling would lead to a 6-fold increase in annual prostate deaths avoided over deaths caused by lack of AS adherence, due to wider PSA screening acceptance.

They also performed numerous model scenarios, modifying inputs, all of which failed to change the final net benefit conclusion.

Overdiagnosis and overtreatment are the major disincentives to prostate-specific antigen (PSA) screening, this disincentive DECREASES if GG1 were labeled as it truly is….a non metastasizing disease.

A man’s initial fears and concerns to rush into treatment are ameliorated if he is told his CURRENT disease is precancerous and will not metastasize; BUT he will still need to diligently monitor progression (AS recommended) to ensure a more aggressive form of the disease is not found at a future date.