The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, November 26, 2013

Active Surveillance: Knowing the Players, Betting the Odds


Prostate cancer screening has led to the diagnosis and treatment of many cancers that would not have become life threatening during a man’s lifetime. Since Mark and I published our book, Invasion of the Prostate Snatchers, stressing the over-treatment of prostate cancer, the ascent of Active Surveillance has become the most game-changing factor in the management of this disease. And yet with the popularity of robotic surgery both doctors and patients are still opting for cutting out prostate with low-grade cancer unnecessarily.

Johns Hopkins was way ahead of the curve with their Active Surveillance program. In 2011, Hopkins published the results of a study involving 769 patients with low-risk prostate cancer who had been deemed eligible for the program. After seven years, only about 50 percent of the men had been treated with surgery or radiation. This meant some 385 men got a pass on one or another of life’s more risky and unpleasant procedures. Furthermore, it must be noted that not a single patient enrolled in the Hopkins’ Active Surveillance program died of prostate cancer.

The best prostate surgeons operate on an extremely small percentage of men over the age of 70, even though they meet the criteria for low risk disease. In fact, Hopkins only intervenes surgically in about 1 percent of those men. On the other hand, nationally, more like 80 percent are undergoing surgery or radiation. More than 90 percent of men over 65 with low to intermediate risk disease undergo treatment even though it is unlikely to extend their lifespan.

Active Surveillance reduces this radical over-treatment of low-risk, indolent cancers while allowing for curative intervention if and when the cancer progresses. Yet despite the obvious virtues of Active Surveillance, the dominant view in prostate care is that everyone who gets diagnosed gets treated in a one-size-fits-all approach regardless of their age, or the grade and stage of their cancer. Which means prostates are continuing to come out at a record pace, even though there is no benefit from the procedure. Senior urologists at top academic medical centers blame a host of reasons, not the least being the pressures on for-profit private hospitals to boost the volume of procedures in order to maintain their annual profit margins. Unfortunately, there are always financial issues involved.

While evidence is mounting that for men with low-risk disease Active Surveillance is both sensible and safe, the challenge is to further refine the protocols for separating out low-risk men from the men facing uncommonly aggressive tumors. In this regard there are some new genetic tests called Prolaris and Oncotype that help detect prostate cancer’s bad actors.

Meanwhile, if your prostate cancer has been diagnosed as low-risk (which has been defined as a Gleason Grade less than 7, a PSA less than 10), and your doctor is recommending immediate radical treatment, my advice to you is to get a second opinion from a doctor who has experience in treating patients with an Active Surveillance protocol. And if the time comes when you do trade Active Surveillance for surgery, never—repeat never—hesitate to ask the surgeon you are considering employing how many radical prostaectomies he performed this year. And last year. And the year before. I have been astonished to learn that hundreds of well-regarded urologists have performed fewer than ten a year. Last time I heard, between 150 and 200 procedures qualified you as “expert.” At that pace, you’d need to be a medically trained vampire to qualify. As for robotic surgery, it makes no great difference: I still want you closing in on 200 procedures, of whatever kind, before you get access to the prostate of any of my friends!

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