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Active surveillancepatient selection and management
Active surveillance for prostate cancer: patient selection and management L. Klotz, MD is a paper published in last month’s Current Oncology. I think it gives a very useful overview of the current issues surrounding Active Surveillance and should be read by any newly diagnosed man or anyone contemplating Active Surveillance as their ‘therapy’ of choice.
Some of the key points are:
1. A diagnosis of cancer often results, at least initially, in “cancer hysteria”—that is, a perfectly understandable reflexive fear of an aggressive life-threatening condition. For some cancers this fear is warranted, but for most men with favourable-risk prostate cancer, their condition is far removed from that of a rampaging, aggressive disease. Most men with favourable-risk prostate cancer are not destined to die of their disease, even in the absence of treatment. This view is echoed by luminaries such as Dr Christopher Logothetis who said many years ago
“One of the problems with prostate cancer is definition. They label it as a cancer, and they force us all to behave in a way that introduces us to a cascade of events that sends us to very morbid therapy. It's sort of like once that cancer label is put on there we are obligated to behave in a certain way, and its driven by physician beliefs and patient beliefs and frequently they don't have anything to do with reality.”
And Dr Jonathon Oppenheimer who said
“For the vast majority of men with a recent diagnosis of prostate cancer the most important question is not what treatment is needed, but whether any treatment at all is required. Active surveillance is the logical choice for most men (and the families that love them) to make.”
2. Some studies demonstrated that prostate cancer typically begins in the third or fourth decade of life yet the median age of death from prostate cancer is about 80 years. Dr Klotz says this implies a 50-year time course from inception to mortality and that most patients have a long window of curability, which is particularly true for patients with favourable-risk, low-volume disease. It also implies that young age at diagnosis should not preclude a surveillance approach. Of course there are tragic cases of young men dying from the disease, but as Dr Klotz says they generally have high-grade disease at the outset and represent a very small proportion of prostate cancer patients. According to the current SEER data less than 10% of cancer deaths (which account for about 3% of all male deaths) occur in men under the age of 54.
3. Although approximately 200 patients have been followed for between 10 and 15 years, it is acknowledged that most of the studies have immature data and it will be another 5-7 years before a median follow-up of fifteen years can be achieved. This will be a good deal longer than many of the published studies for other therapies which often have a median follow-up of five years or even less. In one study where 50% of the surveillance patients were eventually treated, absolutely no difference was observed in the mortality or the metastasis rate at a median follow up of about 8 years.
4. The paper sets out various criteria for the clinical follow-up for men who choose Active Surveillance and it is interesting to note the move away from the concept of frequent biopsy procedures once the basic diagnosis has been confirmed after 12 months. This will diminish what is sometimes referred to as a ‘side effect’ of Active Surveillance.
Choosing Active Surveillance is not without its risks, as are all options for the man diagnosed with prostate cancer. This paper does not deal with any potential loss of quality of life (QOL) that may come with the election of the AS option or make any comparison with QOL issues associated other therapy options.