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ACTIVE SURVEILLANCE IN LOW RISK PROSTATE CANCER

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There is now an "emerging consensus" that supports the use of initial active surveillance in low-risk prostate cancer, according to an essay published online August 8 in the Journal of Clinical Oncology.
At the same time, active surveillance is a "relatively uncommon management strategy," admit the essayists, led by Matthew Cooperberg, MD, from the University of California, San Francisco (UCSF).
Two related challenges have limited the widespread acceptance of active surveillance, say Dr. Cooperberg and his prominent coauthors, Peter Carroll, MD, also from UCSF, and Laurence Klotz, MD, from the University Toronto in Ontario, Canada.
In their essay on the "progress and promise" of active surveillance, the trio identify these 2 big challenges as problems in "defining eligibility" (i.e., who should be followed with active surveillance) and "identifying progression" (i.e., when this strategy should be stopped and replaced with active treatment).
They also introduce a host of other impediments to acceptance of the strategy, including economics. "Active surveillance is labor intensive and reimbursed relatively poorly," they write.
The essayists dramatically cite another retarding factor: patients. For some men, despite all educational efforts of a clinician, "the conversation about surveillance ends at the word cancer," they say.
Dr. Cooperberg and colleagues do not directly say that the practice of urology is at fault for the lack of uptake of active surveillance, but they allude to some responsibility, saying that "cultural biases in favor of aggressive treatment" might be at play.
The behavior of urologists is an important consideration, suggested a medical oncologist not involved with the essay.
"Urologists have been taught that the right way to treat cancer is to take it out," said Richard Lam, MD, from Prostate Oncology Specialists in Marina del Rey, California. This 3-physician practice, which treats about 1500 men with prostate cancer, is headed by medical director Mark Scholz, MD, author of Invasion of the Prostate Snatchers (2010, Other Press), a scathing indictment of the mainstream approach to prostate cancer.
Dr. Lam maintains that urologists "have not been taught to not take out prostate cancer."
"It's almost in their DNA to take it out," he told Medscape Medical News.
"Active surveillance is not a concept that they cannot grasp," said Dr. Lam about urologists. "The question is," he continued, "whether or not the basic principles [of active surveillance] are followed."
"There is very little likelihood that a cancer that is destined to be cured will not be cured if active surveillance is done," Dr. Lam asserts.
However, this is a major concern, as Brantley Thrasher, MD, from the University of Kansas Medical Center in Kansas City, and a spokesperson for the American Urological Association, pointed out in a previous interview with Medscape Medical News.
"Once you know there is a cancer, you have to be very careful," Dr. Thrasher noted. If the patient opts for active surveillance but then is noncompliant with regular follow-up tests, and a metastatic prostate cancer is discovered after a few years, then there is danger — especially in the litigious environment of the United States — of a claim of medical negligence, because there might have been a window of opportunity for curative treatment that was missed, he explained.
Dr. Cooperberg and colleagues also cite "medicolegal" risks as a retardant to the uptake of active surveillance.
But Dr. Lam said that, with a patient who is carefully oriented to active surveillance, "we are not very concerned about lawsuits."
Patient Education Could Change Things
Dr. Lam said that the essay by Dr. Cooperberg and colleagues is "well balanced," and adds that he has admired and followed Dr. Klotz's pioneering work in active surveillance "for years."
But Dr. Lam emphasized the need for patient education about active surveillance, and said that he and his colleagues at Prostate Oncology Specialists work hard to educate patients.
Among the 1500 men with prostate cancer attending their practice, about 400 are on active surveillance.
"It takes a lot of time and empathy to communicate the concept that most prostate cancer is a slow growing disease that doesn't kill people," he said.
"Urologists don't do this," Dr. Lam said.
Education is the key to patient acceptance of active surveillance, he asserted. Foremost, patients need to know that active surveillance is "not a case of writing them off," said Dr. Lam, who provided an example of the kind of simple teaching he uses.
He explains to patients that one of the criteria for judging the appropriateness of active surveillance is the "amount" of cancer. Patients with low-risk cancer are told that as the amount increases, their risk increases. They are asked to think of low-risk prostate cancer as a "marble."
"People don't die of a cancer that is the size of a marble," he explains to patients. If it increases to the size of a "ping pong ball," they will continue to watch and biopsy it. And they take out the cancer that is "like a basketball."
One of the investigators in the Surveillance Therapy Against Radical Treatment (START) trial, the first-ever North American phase 3 trial comparing active surveillance and treatment, also suggested that education can shape patients' attitudes.
When enrolling men for START, Adam Kibel, MD, from the Washington University School of Medicine in St. Louis, Missouri, found that, once educated, "many patients end up being concerned about possibly being randomized to treatment."
Reflecting on "Reflexive" Treatment
Dr. Cooperberg and colleagues make numerous references to the fact that the current approach to the care of men with low-risk prostate cancer is in need of repair.
"In contemporary practice in the United States, diagnosis tends to lead to treatment; thus, as the proportion of prostate cancers diagnosed with low-risk characteristics has grown, overdiagnosis has been associated with high rates of overtreatment," they write.
Overdiagnosis and overtreatment are likely to increase with the American Urological Association's new recommendation to begin screening at age 40 years for most men, they suggest.
Autopsy series have shown that 30% of men in their 30s have histologic evidence of prostate cancer, Dr. Cooperberg and his coauthors point out. Thus, it is especially important that "reflexive treatment should be avoided for young men with low-risk disease, whose period of tumor latency may be prolonged."
In general, urologists need to stop offering surgery to everyone with prostate cancer, suggest the essayists. "Reflexive radical treatment of all new diagnoses is increasingly difficult to justify," they write.
There is evidence now that active surveillance is a sound initial strategy in low-risk prostate cancer. "The data to date are sufficient to conclude that most men with low-risk disease — and likely most with intermediate-risk disease and significant comorbidity — should be offered at least a trial of active surveillance," they write.
Who are the best candidates?
"The obvious candidate for active surveillance is an older man with low-risk prostate cancer," the essayists write. Dr. Lam pointed out that older men with comorbidities such as heart disease, who are less likely to be referred to surgery as a result, are especially obvious candidates.
The essayists concur and further qualify this point. "Cancer risk, comorbidity, and life expectancy should receive greater consideration than chronologic age per se in treatment decision making."
How to define risk progression in this setting is "equally challenging," say the essayists. "Overall, grade progression seems to be the most consistent driver of progression," they write. However, "none" of the end points used to measure progression is "entirely satisfactory."

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