Active Surveillance versus the “Gold Standard”
Ten years ago surgery was called the “Gold Standard,” the treatment to which every other kind of treatment should be compared. Now you rarely encounter the Gold Standard argument to bolster surgery as the preferred treatment approach. What scientific studies led to this change in perspective and why has it taken so long for this change to come about?
Finally, a Clear Answer
The final nail in the “Gold Standard” argument occurred in 2012, when the New England Journal of Medicine published a study by Dr. Timothy Wilt comparing the long-term outcome of surgery versus observation.1 Between 1994 and 2002, seven hundred and thirty-one men volunteered to undergo either surgery or observation based on a coin flip.
No
Benefit for “Good” Cancer, Modest Benefits for “Bad” Cancer
The average age for the whole group of
men was 67. The median PSA was 7.8. The study ultimately concluded that here
was no difference in prostate cancer mortality with either approach. Mortality
was within the expected range of statistical variation (5.8% died in the
surgery group and 8.4% died in the observation group). A small survival benefit for surgery was seen
in men with a PSA over 10. (Mortality
was 12.8% in the observation group and 5.5% in the surgery group.) Dr. Wilt
also reported the side effects of surgery.Even before Dr. Wilt’s report was published, Active Surveillance had been gaining mainstream acceptance in the medical community. Multiple, independently-published studies consistently reach the same conclusion that Active Surveillance is safe. Some of these studies are briefly summarized in the next few paragraphs. The full abstracts are posted on our website at www.keepmyprostate.com.
Do All
Men Have Prostate Cancer?
One of the most compelling arguments
for forgoing radical treatment is based on the fact that prostate cancer is
simply too common in the general population to represent an imminent threat to
life. Studies of prostate glands removed from men dying of unrelated causes
show that by the time they die, most men harbor prostate cancer.1
That prostate cancer is incredibly common in the normal male population is also
supported in another report from the New
England Journal of Medicine where 4,692 healthy men over age 50 with a
normal PSA (average 2.7) volunteered to undergo a simple six-core prostate biopsy.
The resulting biopsies showed that one-fourth
of the men had cancer.2
Many
Studies, Same Conclusion
Additional research has looked into
comparing Active Surveillance with surgery. For example, a study from Johns
Hopkins reported that life expectancy is only extended an average of 1.8 months
by having immediate surgery.3 Another
study in the Journal of Urology
confirms that the grade of the tumor
is an excellent method for determining which type of cancer is safe to monitor
because prostate cancer mortality was almost nonexistent in 12,000 men with Gleason
score of six or less who were monitored
for 12 years after surgery.4
Additional
studies reporting the long-term outcome of Active Surveillance have been
published: In a ten-year study of 1,000 men undergoing observation at Johns
Hopkins Hospital, not a single man has died of prostate cancer or developed
metastases.5 In another study of 450 men undergoing observation in
Toronto that included some men with grade 7 disease, five out of 450 men died
of prostate cancer.6
The
Dark Side of Treatment
The idea of living with cancer may not
seem at all attractive, but once the side effects of surgery are factored in,
Active Surveillance starts to look really good. Unfortunately, the side effects
of radical treatments like surgery are universally underemphasized by doctors
and patients alike. Doctors downplay the effects of surgery because their years
of working in the field accustom them to impotence and incontinence in their
patients. The patients who have had treatment and are lucky enough to have had
a good outcome, sing the praises of treatment because they took a radical step
to remove their cancer and were fortunate to avoid bad consequences. The
patients with bad outcomes are frequently too embarrassed to talk about their
diapers and sexual incapacity. They
minimize the bad effects of the treatment and emphasize their gratefulness
about “having been saved from cancer.”
The
fact is that surgery and radiation cause permanent side effects with astounding
frequency. In a study of 475 men, four
years after having surgery or radiation, less than 20% of men described their
sexual function as returning to normal.7 In another study of 785
men, three years after surgery or seed implantation, less than 20% of men who
had surgery and less than 50% of the men who had seeds described their sexual
function as returning to normal.8 Unfortunately, to many people, all
these statistics are an abstraction. Nevertheless, the tragedy of unnecessarily destroying even one man’s
sexual identity cannot be calculated.
At
First, New Thinking Always Seems Radical
Let me close with an acknowledgement
that Active Surveillance involves a totally new way of thinking. The very first
conference to review the science of Active Surveillance was convened in San
Francisco in 2007. At that time two hundred prostate cancer experts laid down
the basic guidelines for Active Surveillance.
Doctors around the world are still being introduced to the idea of Active
Surveillance. Believe it or not, some doctors have not even heard about
it. Inevitably, it takes time for people
to change. Even so, that’s no reason for you to be trapped by outdated thinking.
3 comments:
I am a new subscriber to your blog and read it with curiosity. I was a gleason 8/75% and 6/5% of sample. I underwent Tomo Therapy two years ago and so far PSA's under 1. The only side effect to date being ED and dry firing - the former helped with the "pill". Knowing a fellow who died of prostate cancer, I think I would have been opposed to "active surveillance" if it had been suggested. With my numbers, what are your thoughts? Most of us who have been there, tend to talk to the newcomers of this group.
What about someone like me who is 50 y/o, is AS appropriate? As see the mean age is 67 in this study.
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