Active Surveillance: Follow-Up Essential

BY RALPH BLUM

 

A recent UCLA study found that a significant percentage of men diagnosed with low-risk prostate cancer who chose "active surveillance," rather than aggressive treatment in order to avoid the debilitating side effects of surgery or radiation, don't follow up with the required tests and office visits.

 

This is an alarming finding, because not being monitored appropriately puts them in danger of the cancer progressing or metastasizing without their knowledge. Before patients decide on active surveillance as a management option for prostate cancer they should agree with their physician on a strict follow-up schedule to closely monitor the cancer.

 

There is no doubt in my mind that active surveillance is the smart treatment option for low-risk prostate cancer.  With other cancers, or if the prostate cancer is aggressive, the main issue is survival. But with low-risk prostate cancer, since long survival is the norm, the most important consideration is quality of life. Having said that, with active surveillance regular check-ups are essential, because when men are watched closely, treatment can be started at the first sign of cancer progression.

 

So what does active surveillance require? How exactly is it carried out?

 

Different centers have different requirements. At a 2007 Active Surveillance Conference, attended by over 200 of the world's leading prostate cancer experts, the attendees recommended a biopsy after one year, subsequently repeating it every two to three years. But as I have often said, I am not a fan of biopsies. So I prefer to recommend doing a repeat targeted biopsy only on the basis of a PSA and prostate imaging with either color Doppler ultrasound or 3T multi-parametric MRI.

 

Here is an Active Surveillance Protocol that Dr. Mark Scholz recommends:

 

• PSA every three months
• Rectal examination every 12 months
• Color Doppler ultrasound annually
• Multi-parametric MRI annually

Whatever protocol your urologist recommends you need to be committed to following it. It may be inconvenient or uncomfortable but the alternative is aggressive treatment that has the potential to leave you with erectile and urinary dysfunction.

 

There is always the consideration to just treat the cancer and be rid of it. But having lived with this disease for over two decades, with my prostate intact, I am a firm believer in avoiding radical treatment and preserving quality of life as long as possible. And if you have low-risk prostate cancer, bear in mind that the longer you can wait before you submit to radical treatment, the better the odds are that research in the field will have advanced, and treatment will have become more effective and less toxic.                                                                

What’s Going On at the Prostate Cancer Research Institute

BY MARK SCHOLZ, MD
In 2016, the PCRI will celebrate its 20^th anniversary.  The PCRI, founded in 1996 by Dr. Stephen Strum and I, was originally funded by a generous grant from the Daniel Freeman Medical Foundation.  This initial grant was spent on hiring Harry Pinchot, aka Helpline Harry. The helpline format adopted at the PCRI was modeled after the work of Lloyd Ney, the founder of PAACT.  PCRI’s helpline presently has four counselors: Jonathan Levy, Silvia Cooper, Bob Each and Charles Kokaska, all who provide unbiased prostate-cancer-related information, free of charge to the public.


PCRI started doing patient-focused conferences in 2006. Since 2006 this has become an annual meeting. The conference has grown in stature through the years by attracting world-renowned prostate cancer experts who are invited to present the latest information on optimal diagnosis and therapy. DVDs of the presentations are distributed throughout the world.  Partly due to the wonderful moderating presence of Dr. Mark Moyad, the conference has grown to be the largest patient-orientated prostate cancer conference in the world.


PCRI makes its biggest impact via its online presence by providing articles and blogs authored by prostate cancer experts from every specialty. But more importantly, PCRI is presently in entering into a new phase, the development of the SHADEs of Blue organizational format, a methodology to help patients sort through the overwhelming amount of information by reducing it into a more manageable bite-sized format.  As we all know, the internet has solved the problem of getting access to information.  Now the biggest problem patients face is information overload. How does one sort through the deluge of unfiltered information?


The development of the SHADES of Blue program will address this problem of information overload by segregating prostate cancer information into five large categories. Three are for the newly-diagnosed, Low, Intermediate and High-Risk, and two are for men with either relapsed disease or metastatic, hormone-resistant disease. The SHADES program is a big undertaking for a small organization like the PCRI, especially considering that we have expanded our conference schedule by now doing two conferences annually with the addition of the Mid-Year Update in March.


Looking to the immediate future, I never been more excited by the PCRI’s potential for making a positive impact in the lives of men with prostate cancer.   If my suspicious are correct, PCRI’s visibility is truly on the verge of taking a big jump.

Photons or Protons? You Choose

BY RALPH BLUM


Following in the footsteps of robotic surgeons, prostate cancer continues to go high-tech. Radiation, for instance, is no longer just radiation. There are now numerous different ways to deliver it. But the two methods I want to write about here are Intensity Modulated Radiation Therapy (IMRT), and Proton Beam Therapy (PBT).


The predominant method in the U.S. for the past decade is IMRT, a complex procedure that precisely targets the prostate gland with multiple beams of high energy light (photons) at different angles and intensities while significantly lowering the risk of damage to the surrounding tissues and organs.  This greater accuracy in targeting also allows the therapist to maximize the radiation dose to the tumor.  IMRT has at least as effective a cure rate as surgery, and without the risks and side effects of a major surgical procedure.


Having said that, I have recently been checking out Proton Beam Therapy, a form of radiation that targets the tumor with charged particles called protons. Several decades ago, Loma Linda University in California was the first to begin administering PBT. At that time, I had a friend who, at 55, developed prostate cancer and was one of the first patients at Loma Linda when proton therapy was at a very early stage.  Bill has been free of cancer for over twenty years, and only recently had a rise in PSA and is discussing further treatment.


Since then, thanks in part to marketing hype, PBT is becoming increasingly popular.  Now, M.D. Anderson, Harvard, and the University of Florida in Jacksonville, are among the major medical centers that have made PBT available. And The Mayo Clinic is building two proton therapy centers (one in Rochester, one in Arizona) at a cost of $380 million. Naturally PBT costs considerably more than IMRT.


When weighing treatment options, patients generally consider two main factors: potential side-effects, and successful outcome. So how do these two therapies measure up? Well, there is considerable controversy in the urologic community. The good news is both therapies have a high cure rate. Studies that have tried to compare IMRT with Proton therapy indicate that the outcomes are quite similar and that the side effects are comparable.  No large randomized trials have been published that directly compare patient outcomes with the different techniques.  So in the end, a treatment decision usually depends on such variables as patient preference and doctor preference.


It is reasonable, therefore, to keep in mind that any medical center that has invested an astronomical amount of money on equipment will end up wanting to use it.

Biopsy, Not PSA, Leads to Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer is way over treated, and the problem starts with over diagnosis.  Once men are diagnosed, the fear of cancer naturally drives them toward radical treatment. In 2011 the US Preventive Services Task Force intervened, trying to stop overtreatment, argued that PSA testing causes more harm than good.

Some have questioned the expertise of the panel because of the lack of representation by urologists, radiation therapists or medical oncologists --the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel constituents appear entirely appropriate to comment on screening, because this is an area of medicine usually handled by primary care doctors.  The panel members consisted of twelve MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force agrees that PSA screening may save lives. Their judgment, however, was that too few lives are saved to justify thousands of men getting unnecessary radical treatment. One statistic indicates that a thousand men must be screened to save one life within the next 12 years.

Personally, I agree with the panel in regards to over diagnosis is a root cause of over treatment. However, simply discarding PSA is an oversimplification. PSA can detect a variety of problems infection and benign prostate enlargement. Actually, the majority of men with elevated PSA, don’t have prostate cancer.

No, the real problem is after a PSA test rises. Every year, a million men are advised to have a dozen, large-bore needles jabbed into their rectums “Just to be sure there is no cancer.”  Such behavior sounds ridiculous, but really, it is just the survival instinct in action. People will do practically anything when they fear for their lives.

So if not a biopsy to evaluate an elevated PSA, what’s next?

First, the fear must be faced. Ralph Waldo Emerson says “Knowledge is the antidote to fear.” So let’s look at some basic facts:

• One out of 38 men die of prostate cancer
• One out of seven men are diagnosed with prostate cancer
• In men who are “diagnosed”
  • Five-year survival is 100%
  • Ten-year survival is 99%
  • Fifteen-year survival is 94%
    

Considering it is cancer, survival rates are great! At least these numbers should overcome any urge to rush. Clearly there is plenty of time is to study and learn more. Confusion arises because a minority of prostate cancers can indeed be dangerous. Not as dangerous as lung or pancreas cancer which kill within months. However, demise from prostate cancer certainly qualifies as “dangerous,” even if it is rather infrequent and much postponed.

These statistics reveal something else that is quite useful. Prostate management issues are of long-range nature, like saving for college or for retirement. Just as expert financial planners are limited in the ability to make predictions about economic activity ten years in the future, doctors should be equally humble in their pronouncements about the future of prostate cancer. We don’t know for sure, but we strongly suspect there will be substantial breakthroughs in the diagnosis and treatment of prostate cancer in the next ten years.

For the short term, I think the best way to proceed is with imaging the prostate with a 3Tmulti-parametric MRI or color Doppler ultrasound. Scans are about as accurate as a random biopsy for detecting aggressive cancers and they usually fail to detect the harmless low grade types, which is a good thing. However, if there is a worrisome abnormality, a targeted biopsy with just a couple cores is needed.

Over-diagnosis and over-treatment is not due to PSA. It’s the misguided policy of rushing into an immediate random biopsy whenever there is a slight elevation.  .The random biopsy procedure should be abandoned.  PSA abnormalities should be evaluated with prostate imaging A targeted biopsy can be considered in men who have a distinct abnormality detected by imaging.