Active Surveillance- Systematic Review of Interventions

@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 Oh sure, NO disagreement that higher Gleason Score Portends higher chance for BCR. And add in all the side dishes of EPE, Cribriform, IDC and family history and you have a whole range of probabilities.
But even then, there are scores of men right here on the forum with small G3+4’s or even 5% G4+3’s with no extra factors to enhance aggressiveness , and even they end up with BCR…how?
Also, in that cohort of 6682 men, you don’t say what percentage of men with BCR was assigned to what particular Gleason Score (how many 3+4…or 4+3, or 4+4, etc.) and other important pathological factors; there could have been a large group of men in the lower range and a much smaller group in the upper range, but all in all they averaged 30% combined.
I agree that it’s not an accurate representation of the underlying issues - not even close - but the RO I mentioned was probably generalizing for my benefit simply to illustrate that surgery is definitely not always a cure. Best,
Phil

@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.