Active Surveillance- Systematic Review of Interventions

@paulsweeney

Paul, I wanted to ask you this.

I used to exercise a lot, testosterone levels were constantly rising. Everything was leading up to my doctor saying that if my testosterone kept rising, I'd have to have my balls amputated.

I decided to take a rather unusual approach. I actually stopped moving a lot and reduced my exercise to almost nothing. After that, my testosterone levels dropped again.

What do you think about what I wrote about the connection between testosterone levels and exercise?

I read about IGF on your website. Is it scientifically proven that it reduces the progression of prostate cancer?

Thank you, I await your reply!

@denis76
While Exercise provides vital muscle-preserving benefits, it cannot override the biochemical mechanism of ADT. It can’t keep your testosterone up for more than a very short time.

Are you on the agonist version of ADT (Lupron) or the antagonist version (Firmagon, Orgovyx). Switching to the other version may be what you need to keep the testosterone down.

@jeffmarc

ADT still on diphereline (Triptorelin)

My doctor said that if my testosterone doesn't rise above a certain level and my PSA remains low, I shouldn't change my medications—they're both working.

Remember, my testosterone levels have dropped. Knock on wood.

@paulsweeney

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.

@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

@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.

@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