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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="darkgreen"]Hi zzyzzy (and Brendon),

I'm responding to your post #19 of a couple of days ago in which you expressed so well some of the confusion and doubt felt by many patients and their loved ones about prostate cancer. My key message is that there is a path through that swamp where you are having such a hard time figuring out what is true regarding active surveillance. The truth is not hard to see if you look at the key facts from a sound vantage point, which is why major medical professional organizations are now enthusiastic about active surveillance. I'll try to explain that in green below, using excerpts from your post, and I'll add detail that I think others of us will also want to learn how to look at such issues. I hope this helps.

While Brendon's father is clearly not a candidate for active surveillance, I'm glad you raised the issue on his thread as the following information may help him and his father educate other patients who are coming to them for advice after being diagnosed.[/COLOR]

[QUOTE]All of the above is true, and strangely, none of the above is true as well. Prostate cancer lulls us into thinking every low grade lesion will behave as we expect.[/QUOTE]

[COLOR="DarkGreen"]No patient or doctor should assume that, and there are at least several reasons without even thinking hard about it. First, the "grade" of the patients cancer cells is based solely on the biopsy sample, and while the 10 to 12 or more well-placed samples typically taken today represent the whole prostate with substantial accuracy, there is ample room for error. That's just one of the reasons that [I][U]not a single one of the major active surveillance programs rely solely on the grades making up the Gleason score[/U][/I], one of the key diagnostic assessments of the cancer. In fact, the major programs all use the Gleason score as an important element in eligibility for active surveillance, but they use a number of other important factors as well. While this multi-factor approach goes a long way toward eliminating the dangerous surprise you are concerned about, the active surveillance program itself - the monitoring, has proven to virtually eliminate such surprises, doing as well as radiation or surgery. This is a vital point. It has been covered in the past on this board, but I can give you some leads if you would like them.

A second important reason not to be complacent just because the grades (hence, Gleason score) are low is that there may be just a small number of really dangerous cells lurking in the prostate (or already metastatic) that have not been picked up in the diagnostic and staging work-up. Such cells are fortunately extremely rare, but there are at least two types worthy of mention, "small-cell" prostate cancer and "endometrial" cell prostate cancer, the latter named because it resembles female anatomy. Among other stealthy characteristics, these cells may produce little or no PSA, despite being highly aggressive. Unfortunately, whatever approach is taken - such as surgery, radiation, or active surveillance, if some of these cells have been missed and are beyond the range of the therapy, the patients chances of a recurrence free survival and overall survival are substantially reduced. It is important to recognize that this is a problem no matter what approach is taken; active surveillance is not inferior to radiation or surgery here, as the statistics bear out.[/COLOR]

[QUOTE]Then the inevitable exception occurs, and a 50 year old man develops metastatic disease under "surveillance" and dies the slow, horrible death that prostate cancer can bring, while some high grade lesions do not progress at all for years.[/QUOTE]

[COLOR="darkgreen"]All patients should be reassured that such a situation is extremely rare, as discussed above, and I can provide statistics if you would like. Using the word "inevitable" may make some patients think that this is a prominent risk that they should weigh in the balance, and, in fact, research has proven that that is not so and that fear about that risk is not wise.

Please do not take my word for it but instead take a look yourself at the research reports being published by the major active surveillance programs, which have been mentioned previously. I particularly recommend papers involving Dr. Laurence Klotz, as his is a well-reported program that dates from 1995.

You are worried that a man on active surveillance who does prove to have more aggressive cancer, which would be picked up fairly soon under active surveillance monitoring, "dies the slow, horrible death that prostate cancer can bring."

On the contrary, research has pretty much proven that men with more aggressive cancer are usually picked up by the second or third year of surveillance, and - here's the really wonderful news - [I][U]their chances of cure or cancer control are virtually the same as if they had chosen treatment right off instead of surveillance![/U][/I]

However, even for the few who are not cured (in proportions very similar to those not cured by initial radiation or surgery), modern hormonal therapy and other options make many years of quality life likely, with a good shot of surviving the prostate cancer and dying of something else. There are threads related to this on this board, but I would be happy to elaborate if that would help.

The fact is, you can find any opinion you want on prostate cancer screening, diagnosis and treatment in a book by yet another "expert."

[COLOR="darkgreen"]I'll agree with that. Even the medical director of the American Cancer Society, a medical oncologist who has treated many prostate cancer patients named Otis Brawley, is badly mistaken about the value of screening. In part he has been misled, as have quite a few others, by some very premature and flawed studies published last year by the New England Journal of Medicine. Being aware of such incidents has taught me that you better not park your brain when you are presented information, no matter the source. However, in this discussion we are focusing on active surveillance, and the picture is clear and reliable.

Here's a way to help figure out which doctors and researchers are really "expert." Take a look at and see what papers they have published on the issue. In particular, look for papers where they are listed as the only, first or last author, as those are the most important positions for typical studies. Then consider whether the journal in which a paper appears is a major, peer-reviewed journal or a secondary journal. Judging that takes a little experience or tips from someone who is savvy, but it's not too hard to catch on to which publications are the heavyweights.

Let's use Dr. Laurence Klotz and his program of active surveillance in Toronto as an example. I just did that using this search string (without the quotation marks): " klotz l [au] AND prostate cancer " and got 166 hits. Now that is actually an extremely high number, with most researchers being proud if they can get even a handful of publications. A quick glance tells us that many of these papers are in major journals. It's also easy to observe that he is frequently the only, first or final author on these papers. That is enough to give us high confidence that we are dealing with a physician who is expert in some areas of prostate cancer. The next question is whether he is heavily involved in active surveillance. That's important as experts in one are of the disease, such as radiation, are often not at all expert in other areas, for example, surgery.

We can do a refined search to take this next step. I just did that with " klotz l [au] AND prostate cancer AND active surveillance " and the search yielded 31 hits, again a very high number for a subfield of prostate cancer. Checking the publications and positions in the author lists yields the same conclusion: Dr. Klotz appears to be an expert in active surveillance.

It's possible to verify this by checking whether he presents to major professional medical associations on active surveillance (he does), but that is not as simple as checking PubMed so I won't go into it here.

The bottom line is that Dr. Klotz is an expert in active surveillance, and so are leaders of the other major active surveillance programs mentioned earlier.

There is only one highly prominent prostate cancer expert whom I know of who is opposed to active surveillance. He is Dr. William Catalona, a prostate cancer surgery pioneer and an important researcher. However, if you the search string " catalona w [au] AND prostate cancer AND active surveillance ", you get only four hits. In the most recent, he makes a case against active surveillance using eligibility standards that the active surveillance experts would consider far too loose. The second paper has only a slight bearing on active surveillance, using only one of the criteria typically employed instead of the approximately six that experts are using. The third paper uses only one of a set of criteria, instead of the multi-criterion combination. The fourth is a very short opinion piece in a non-major journal in which he urges immediate treatment instead of surveillance for low-risk men, but my impression is that he is just making assertions without support and is disregarding important, well-established research. There is nothing to show that Dr. Catalona is directly involved in a program of active surveillance. While his research contributes somewhat to active surveillance technology, it should be clear that Dr. Catalona is not expert in active surveillance. Unfortunately, in my view, he publishes a newsletter that a number of survivors have seen, and his views on active surveillance get a prominence they do not merit.

Regarding the book "Invasion of the Prostate Snatchers," I'll just say that in my opinion the medical co-author is a true established expert, but check the recent thread reviewing the book if you want to see more about that. If you have a question, I'll be glad to answer it. That said, I see it as you do that not all books on prostate cancer measure up to the claims on their jackets.[/COLOR]

[QUOTE]The controversy over this disease will not go away, the studies are frequently so contradictory as to frustrate all of us, and, as in the studies quoted above, are colored by a need for 15 minutes of fame.[/QUOTE]

[COLOR="darkgreen"]Many of us are aware that the media are prone to butchering the truth in the medical research they report. However, we are really fortunate that the "15 minutes of fame" type claims are [I][U]not[/U][/I] the foundation for active surveillance. The Klotz series is the oldest, dating from 1995, with hundreds of patients and some now at the fifteen year point and still on surveillance. As you can see from PubMed, a number of progress reports have been issued, in major journals, and it has been examined from numerous angles over the years. Other active surveillance programs have also diligently published in prestigious journals. I find the quality of following up their active surveillance patients to be extraordinarily impressive.

When you look at the leaders of these programs, you see highly regarded doctors, typically top leaders in their institutions. These are people who hardly need an additional 15 minutes of fame.

There is one other very important point: rather than the active surveillance research results being at all contradictory, there is an unusual degree of convergence and consistency. That both surprised and impressed me. Take a look at PubMed. You will see that too.

I hope this explanation has helped remove the fog from what can be a confusing landscape of claims and counterclaims. With some effort, it is possible to see what is true and what is false regarding a number of so-called controversial issues in prostate cancer.

Take care,

Jim :wave:[/COLOR]

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