Study: Many men with prostate cancer can avoid early surgery – – UrologyTimes

Many men with prostate cancer do not need immediate treatment, especially if they have low PSA scores or low-risk tumors that are unlikely to grow and spread, according to a multicenter study that suggests such men who undergo radical prostatectomy fare no better than those undergoing observation.

The study, published in the New England Journal of Medicine (2012; 367:203-13), drew a fast response from the AUA, which pointed out that the study’s data show the benefit of surgery in high-risk patients.

via Study: Many men with prostate cancer can avoid early surgery – – UrologyTimes.

This was a summary of a recent study published in the NEJM.  It reaffirms that active surveillance is a good option for men with early stage and less aggressive prostate cancer.  At the 10 years, patients that had died were about equally likely to die of prostate cancer and other causes.

The important thing to keep in mind is that this does not apply to young men who may have 30-40 years to live.

Prostate Cancer Screening: Moving Beyond PSA – Renal and Urology News

In nearly 1,000 men undergoing initial or repeat biopsy, these investigators found that urinary PCA3 prior to a prostate biopsy improved the prediction of PCa and high-grade disease with a high positive predictive value 90% in the initial biopsy setting and a high negative predictive value 88% in the repeat biopsy setting. The investigators conclude that counseling men undergoing prostate biopsy in the context of PCA3 would reduce the burden of prostate biopsies.

via Prostate Cancer Screening: Moving Beyond PSA – Renal and Urology News.

 

I have been using PCA-3 tests in a variety of ways.  I perform it yearly for men at high risk of prostate cancer, to determine if men need repeat prostate biopsies, and also in my active surveillance prostate cancer patients.

5-ARI delays prostate cancer progression in men with low-risk disease – ModernMedicine

The 5-alpha-reductase inhibitor dutasteride Avodart appears to delay disease progression and the initiation of active treatment in men with low-risk, localized prostate cancer, results of a 3-year international clinical trial indicate.Treatment with dutasteride also reduces cancer-related anxiety, study authors found.”The results prove that using active surveillance plus dutasteride is a viable, safe, and effective treatment option for men who often undergo aggressive local treatment despite low risk of dying from the disease,” said first author Neil Fleshner, MD, of the University of Toronto’s Princess Margaret Hospital.

via 5-ARI delays prostate cancer progression in men with low-risk disease – – ModernMedicine.

This is the first study I’ve seen that shows that 5-alpha-reductase inhibitors may help slow the progression of prostate cancer.  These medicines are tolerated well by most patients and treatment with avodart can be considered.

Dutasteride Slows Prostate Cancer Progression – Renal and Urology News

ORLANDO—Dutasteride, a drug widely prescribed for treating benign prostatic enlargement, lowers the risk of prostate cancer PCa progression in men undergoing active surveillance for the disease, researchers concluded.

via Dutasteride Slows Prostate Cancer Progression – Renal and Urology News.

Dutasteride has been used for BPH and is thought to help reduce the risk of developing prostate cancer.  This study also supports its use for men on active surveillance.  The medicine is mostly used for the treatment of benign enlargement of the prostate and can have sexual side effects in a small percentage of men.

MedWire News – Oncology – PCA3 predicts prostate tumor volume and could indicate AS suitability

MedWire News: Prostate cancer patients urinary prostate cancer antigen 3 PCA3 scores are strongly indicative of tumor volume, and could be a useful marker of suitability for treatment with active surveillance AS, study findings show.

via MedWire News – Oncology – PCA3 predicts prostate tumor volume and could indicate AS suitability.

I have been using PCA3 tests to estimate tumor burden for men choosing active surveillance for about 2 years.  I also check a PCA3 test after some time for men on active surveillance.  The values that are considered to be significant will need to be studied.

Robotic prostatectomy findings in patients with a single microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy

A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?
Source: Urotoday

While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5  risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.

The team at the University of Chicago looked at patients with only 1 small focus of cancer that was the lower grade (6) on biopsy. Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 [higher gleason score] (18%) and upstaging [cancer outside the prostate] in 16 (8%). I performed a similar study almost 2 years ago that also found the amount and type of cancer is underestimated on biopsy.

Determinants of Long-Term Retention of Prostate Cancer Patients in Active Surveillance Management Programs

From Urotoday and the AUA

Of the 2134 PCa cases, 169 (7.9%) had AS as their initial management. Of the 169 AS cases, 89 (53%) remained untreated throughout follow-up (mean 7.1 years) and the remaining 47% received treatment an average of 3.1 years post-diagnosis. Significant predictors of eventual active treatment in multivariate models included younger age at diagnosis (60-69 vs. 70+ years), higher Gleason score (>6 vs. <6), and higher prostate cancer aggressiveness/risk. The researchers observed similar rates for development of clinical metastases and PCa death in both AS and immediate treatment groups, respectively (metastases: N=8 and N=92, 6.5 vs. 6.7 events per 1,000 person-years, p=1.0; PCa death: N=4 and N=51, 2.4 vs. 2.7 deaths per 1,000 person-yrs, p=1.0).

This one study shows that men that did active surveillance, needed therapy about half of the time. The results seemed similar for both groups. My main concern is that we do not know the cancer characteristics of the patients. It is possible that the active surveillance patients had less cancer than the treated patients and should have done better.
I also think that waiting 3 years to treat someone may later the treatment approach and possibly lead to more side effects after therapy.

Active Surveillance for Prostate Cancer Patients

From Medscape

May 12, 2008 — The urine test for the PCA3 gene, already marketed for use in diagnosing prostate cancer, could also be useful in prognostication. It might have clinical application in selecting men with low-grade and low-volume tumors who would be suitable candidates for active surveillance, say researchers writing in the May issue of the Journal of Urology.
The PCA3 urine test, marketed in Europe by Gen-Probe, has been shown in previous studies to be more accurate in diagnosing early prostate cancer than serum levels of prostate-specific antigen (PSA).

I usually use the PCA 3 test for men who have had a negative biopsy and we are considering performing a second one. I usualy use it for men with high grade PIN after one biopsy. If the PCA 3 is positive, I usually perform a second biopsy. I have not looked at my data to see if the above correlation exists, but that would be interesting.
I also am not sure if you can use PCA 3 tests that are taken a few months apart to mean anything. For example, would a rise in PCA 3 be expected if a man develops cancer or the cancer is growing?

Watchful waiting for prostate cancer

UroToday – European Urology – Watching the Face of Janus- Active Surveillance as a Strategy to Reduce Overtreatment for Localised Prostate Cancer
A good abstract by Swedish urologists that addresses many of the issues for watchful waiting.
It points out that the best candidates have a small amount of gleason 6 cancer. Most men did well for several years with this option.
These people should have repeat biopsies at intervals and may have a negative psychological impact from choosing this therapy.
I always discuss watchful waiting as a possible therapy with newly diagnosed cancer.

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