What Types of Prostate Cancer Patients Should Choose Active Surveillance?

Dr. Bevan-Thomas discusses what kinds of patients should choose active surveillance

122569105Active surveillance is generally for patients that have lower grade prostate cancer because those cancers tend to grow more slowly. But, there has been a debate for a number of years about the over- and under- treatment of prostate cancer, and whether some prostate cancers need to be treated at all.

The short answer is that not all prostate cancers will benefit from treatment, but physicians have to make sure that they are not under treating prostate cancer because it is very difficult, or impossible, to go back in time and take several years back when that patient actually had localized prostate cancer.

The goal of prostate cancer treatment is getting those patients early enough so physicians have a much better chance of curing those patients.

For more, watch Dr. Bevan-Thomas in this video.

Video Transcript

Richard Bevan-Thomas MD:  Hey folks, this is Dr. Richard Bevan-Thomas coming in for Prostate Cancer Live chatting with you today about a very interesting paper that was presented at the Genitourinary Cancer Symposium in Orlando and this is 2015, so the topic of this particular paper and this actually presentation was active surveillance of intermediate risk prostate cancer associated with decreased survival.  Okay so first of all that’s a mouthful so where we break things down that’s what we do here on Prostate Cancer Live, so everybody understands, what we are talking about from the grassroots, so part one is that people should understand what active surveillance is by now.  Active surveillance is for patients that have routinely lower grade prostate cancer and those cancers that actually tend to grow slower, so there has been a debate for a number of years about do we have to treat all prostate cancers and the answer is we don’t, but we have to make sure that we are not under treating prostate cancer because it is very difficult i.e. impossible to go back in time and take several years back when that patient actually had localized prostate cancer. 

The goal of prostate cancer is getting those patients early enough and if we need to treat them we have a much better chance of curing those patients, so when a patient walks in to the urologist office and he is diagnosed with prostate cancer, one of the first thing that we are going to do is we are going to classify those patients in terms of their grade, Gleason grade, and the score that they have. 

According that score actually will classify them in terms of their risk stratification.  Okay, so let’s talk a little bit about this, so again active surveillance is following those patients very closely, our protocol at USMD is very similar to John Hopkins we are in the sense that we get the original biopsy, we do a biopsy at one-year, we have actually switched to have biopsies every two years thereafter that is going to be the most definitive way in which we find whether those patients can continue to remain good candidates for active surveillance.  If we find that they have either higher volume of disease or an intermediate or high grade disease, we are now shifting gears and actually going in to a more aggressive approach which is either going to be surgery, radiation, or another type of intervention for those patients.  On this particular patient and again we look at this from, this is the Canadian cohort from Dr. Clarks and company up there, who really have one of the longest number and a longest running number of patients actually with active surveillance, very-very interesting paper here.  What is this say, the patient with intermediate risk and intermediate risk is defined via PSA above 10, but ideally of those patients actually with Gleason 7 or greater prostate cancer, but those are really the two things that we are looking at is a PSA above 10 or Gleason’s 7 or greater prostate cancer, they looked at these patients and what happened with 15 years which is our big question is that if we follow those patients with low grade prostate cancer how many of those patients might be missing out a little bit in other words could they potentially either died of this disease or have progression or did we really make the wrong decision, so for a number of these patients they actually elected to follow this conservatively in terms of their prostate cancer. 

Let’s talk about those low risk patients, so the low risks patients with the Gleason 6 prostate cancers and the PSA below 10 of those patients who are on that roughly again 3.7%, so almost 4% of those patients actually died of prostate cancer in 15 years, so a little bit higher than I would have imagined, but nonetheless 4% deaths from prostate cancer with a low grade disease, you can imagine a low grade disease very low mortality.  Here, is the quencher, so the patients with intermediate grade disease, they decided that they didn’t want to actually get their prostate cancer treated and they followed it excessively, 11.5% of those patients died of prostate cancer within 15 years, so we are really looking at a pretty significant increased risk of those patients with intermediate cancer that actually you are dying of prostate cancer.  I try to reiterate this to my patients often which is, number one, are you a good candidate for active surveillance.  So, that’s the number one thing that we look at.  We go in and we say okay are you a low risk, are you intermediate risk, and are you at high risk.  If you are in intermediate risk, are you going to be the right patient to follow that and I think this paper answers that which is again it has a 3.75 times increased the risk of dying of that disease within 15 years very important stuff here, so what is the takeaway from this paper, the takeaway from this paper is a few things, number one is that patients with low grade and low risk prostate cancer actually still have a low risk of dying of this disease within the first 15 years, 4% okay give or take 3.7% or 4% still low risk if you one of those 4%, that’s obviously a bad day for you, but it still a very low number. 

If you are in intermediate risk, we start bumping up those numbers that’s not a number that we want to see certainly for treatment of prostate cancer, so if you are in intermediate risk category really think twice about this.  One of things that we do is number one is that we are very careful about patients with intermediate risk.  We look at their life expectancy for that, sometimes we actually run a further genetic test on those patients, the Oncotype test is one of the many tests that we run on this and it gives us more information about the risk that patient is truly an intermediate risk patient because we certainly don’t want to see further progression of those cancers, have that discussion with your doctor, are you the right patient for this because if the cancer gets outside of the prostate and becomes metastatic, we cannot cure those patients.  We can keep those patients around for a while, but we cannot cure them and again the majority of time what we are trying to do is find patients early treat them, cure them, and then getting them back to live an optimum health.  This is Dr. Richard Bevan-Thomas at Prostate Cancer Live, signing out.

Dr. Richard Bevan-Thomas
Dr. Bevan-Thomas is the Medical Director for Prostate Cancer Live. A graduate of Duke University, Rich received both a master’s degree in anatomy and his medical degree from St. Louis University School of Medicine. He completed residency training in urologic surgery at the University of Texas Houston Health Science Center and the renowned MD Anderson Cancer Center, also in Houston. In 2002, he received two top honors in his field; the Pfizer Scholar in Urology and the Gerald G. Murphy Scholar in Urology. Dr. Bevan-Thomas will remain on the leading edge of robotic surgery and cryosurgery at USMD Prostate Cancer Center and will continue offering patients the latest clinical trials in prostate cancer treatment. He continues his teaching and physician proctoring interests as well as instructing in robotic surgery.

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