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Cancer: Prostate Message Board


Cancer: Prostate Board Index


Men diagnosed with low risk prostate cancer that also have certain other favorable case characteristics may be able to take an "Active Surveillance" approach. This is a much more effective approach than simple "watchful waiting" to see if you will get clobbered by prostate cancer. But what is really impressive to me as a survivor is that major surgical prostate cancer centers are recommending this approach as a reasonable option for truly low risk men. :angel: It makes me wish I had had a case that was suitable for this approach.

Most definitions of low risk include a PSA less than 10 (the lower the better), a Gleason of 6 or less (with no Gleason Grade 4 or 5 cancer), stage 1 or 2a, and no more than 50% of a biopsy core positive. Another recent key factor is that the PSA did not rise at a rate of more than 2 in the year before diagnosis; that's an important risk factor even if the other factors are favorable. Another factor is only one or two biopsy cores positive, or a low percentage positive if many cores are taken. One book suggests the PSA density should not exceed .1. Not all the studies use all these factors, and some use additional factors. For low-risk men of 75 and older, or for those with significant other illnesses such as cardiovascular conditions, or especially older men with significant conditions, this approach deserves very serious consideration. But some doctors feel it is a viable option for men of any age. :)

Repeat biopsies are a key step for monitoring deferred therapy, and a negative biopsy or one like the first are additional favorable indicators. For those wanting extra assurance (that would have been me), a color Doppler ultrasound biopsy, conducted by an expert (there are only a handful in the US) is quite good at locating the tumors in the prostate; if they are near the capsule edge in an area where the capsule is thin, such as the apex, or near openings where the nerves exit, that ups the risk of deferring. Certain markers of aggressiveness can also be checked if desired, such as p53, bcl-2, ploidy, PAP, VEGF, etc.

However, this option, like the others, takes careful thought and follow-up monitoring. It's a tough call however you go. At least with deferring therapy, you have a good shot at a fallback therapy like surgery, radiation or hormonal blockade if the deferred approach comes up short. :) The great things about deferring therapy are that you give yourself more good years without dealing with side effects that many of us will experience from the various therapies, and you avoid a lot of expense and the burden of a major treatment. :) Of course the big payoff is when a patient is able to defer therapy for the rest of his life with never a serious threat from his prostate cancer. :) Moreover, in this fast-developing field of medicine, the treatments, tests, etc., will almost surely have improved while you were deferring therapy. :)(There have been great improvements in the eight years I have been a prostate cancer survivor.) In fact, a number of leading experts believe a cure is only a few years away.

It used to be thought that men deferring therapy were taking a big gamble. A lot of us in the past (and still now) could not stand the idea of living with cancer; that's changing as many low-risk patients are realizing that an indolent prostate cancer can be like having an appendix -- something you can get comfortable living with. :) (One leading expert recently compared the range of aggressiveness as going from the risk of a case of dandruff at the low end all the way up to a case of acute leukemia. We don't want to overreact if all we have is the equivalent of dandruff.) Now we have a much better picture of the odds, and the odds are not bad, though there is still some risk. Nothing in this game is risk free, unfortunately. Note that deferring therapy is not the same thing as burying your head in the sand and watchfully waiting until you get clobbered with symptoms of prostate cancer. The idea here is that you watch, put to work a program to hold down the cancer, and make a timely move to a major therapy if advance indicators show signs of trouble. Major Active Surveillance programs are finding that they are having great success in catching any cancers that prove aggressive while they are still in the prostate capsule and potentially curable.

In the past few years, for the first time, we have studies from major surgical centers, involving some of our most expert surgical and pathologist teams, indicating that major therapy can fairly safely be deferred with fairly low risk for low-risk prostate cancer patients and that deferring therapy is a reasonable choice for these patients. The main studies and programs I know of are from the U. of Toronto (leader Dr. Lawrence Klotz) , Johns Hopkins (leader Dr. H. Ballentine Carter with Drs. Patrick Walsh, and Dr. Jonathan Epstein also on the team, and Dr. Christopher Warlick now at the U. Of Minnesota Medical School), Memorial Sloan Kettering (leader Dr. Peter Scardino), and Erasmus University in the Netherlands (leader Dr. Fritz Schroder).

Johns Hopkins and Memorial Sloan Kettering were especially focusing on older men (more or less 70 and older, as I recall), but the Netherlands study speculated that this approach may be reasonable for younger men, say about 55, and Dr. Lawrence Klotz, of the University of Toronto, Sunnybrook, has stated that he is comfortable with this approach for men of any age, :) provided that younger men are even more carefully pre-screened and monitored.

Major cancer centers at MD Anderson and the University of California at San Francisco (leader Dr. Peter Carroll) have more recently contributed their studies favorable to active surveillance. Dr. Stephen Freedland from the Duke University Medical School was on an active surveillance panel moderated by Dr. Christopher Logothetis of MD Anderson with Drs. Klotz, Schroder, and Warlick at the IMPaCT Conference in Atlanta sponsored by the Prostate Cancer Research Program of the Congressionally Directed Medical Research Program. There are many more active surveillance programs, but the foregoing list gives an idea how seriously this option is taken by major centers and leading doctors. Abstracts of papers in the body of published research on active surveillance (also known as “deferred therapy,” “expectant management,” “medical management,” and other names) can be found on [url]www.pubmed.gov[/url], the free US Government public medicine website.

AND, I don't believe any of these studies tracked whether patients were implementing a program to try to hold the PC at bay or to knock it down, though Dr. Freedland spoke about that at the IMPaCT Conference. There is now a growing body of evidence that a diet, nutrition, supplements, exercise and stress reduction program, perhaps with low-key medications, is effective for many low-risk men and helpful to others at higher risk. :) Some fairly well established key elements are lycopene (from cooked and processed tomatoes), selenium, vitamin E with gamma tocopherol instead of just alpha, omega 3 fatty acids from fish or good quality fish oil, vitamin D3, and soy. (Vitamin D3 has gotten a lot of attention in just the past two or three years.) Certain supportive low-key medications like Proscar and Avodart and Celebrex also seem to help. Some doctors suggests oral bone density medications like Fosamax and Actonel as well.

It is also worth mentioning that active surveillance has been a major emphasis in some of the key medical association conferences in 2007. The conference for the medical oncologists association had three presentations/papers on active surveillance of just twelve total papers in the section of their Education Book on genitourinary cancers in 2007 for their annual meeting. The Education Book is the key information that medical associations want to communicate to their members. Vu-graphs and audio recordings of the talks are available on the web for the public.

I've become educated in prostate cancer through the School of Hard Knocks and have not been enrolled in medical education. I feel I'm able to help provide leads, but patients interested in this need to do enough research to choose their own course.

Jim





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