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Cancer: Prostate Message Board

Cancer: Prostate Board Index

I think AS is a great option for you. NCCN hospitals, most of the top cancer centers in America, now include AS as a recommended therapy for all men with low risk PC, regardless of age. Some are even pushing the boundaries to men with Gleason 3+4. One of the misperceptions I often run into is a logical fallacy based on symmetry: It is true that Gleason grade 5 cells progressed from 4s which progressed from 3s. However many men believe that 3s will eventually progress to 4s and 5s. This is most often not true. So there may be no reason to ever seek treatment with all the quality of life issues that come with treatment.

As you know, the critical part of AS is that it's "active" -- there are many steps you have to take in monitoring it. AS programs vary somewhat from institution to institution, but they all include PSA tests every 3 months, DREs every 6 months and repeat biopsies at some point. Some advocate having a second biopsy after a year, just in case something was missed on the first biopsy. Thereafter, biopsies may only be necessary every 4 years.

PSA isn't the only biomarker anymore. The FDA-approved biomarkers now also include % free PSA, PCA3 and -2ProPSA. -2ProPSA is combined with % free PSA to calculate a quantity called the Prostate Health Index (PHI) which seems to be a very good indicator of risk of progression.

Imaging may also be of great benefit too. There are a few doctors who are qualified to use Color Doppler Ultrasound and Shear Wave Elastography Ultrasound that can detect lesions of only a few millimeters. There are some kinds of MRI, like Spectroscopy, diffusion-weighted and dynamic contrast enhanced, and others (collectively called multi-parametric MRIs) that are getting better at cancer detection. MRI-Spect has recently been used to identify Gleason grade as well, without requiring a biopsy. I have a friend who just had a second annual Color Doppler US and saw no growth in his two lesions. That obviated the need for a second biopsy. Needless to say, he is very happy.

Different institutions/doctors follow slightly different AS protocols.With all these tools, you can expect to know with plenty of lead time if the cancer begins to progress. Here's a good discussion of AS by Dr. Klotz, the "Father of Acive Surveillance":

- Allen
Hi folks ..

I had appt with Dr. Thompson at UTSA Health Science Ctr last week. It went well, we talked thoroughly about my status and options along with DRE, etc. He was open about all of my options, but is quite supportive of AS as an appropriate option in my case and that's where I'm heading now.

My background for reference -- PSA stats: 3/11, 2.3; 11/11, 4.6; 4/12, 3.6; 7/12, 3.4. Biopsy performed 1/12 (based on sudden PSA doubling) with positive diagnosis -- Gleason 3+3, 2 of 12 sites, with 20% and 4% of those samples respectively. So, I am early stage, but big question is what to do now with relatively younger age of 56.

My biggest concern is side effects and quality of life from aggressive treatment. I have read many books and journal articles over past 6 mos, and aggressively pursued consults with surgeons, radiologists, and oncologist. I am motivated towards AS choice, as long as it is in fact a viable choice now.

Dr. Thompson and I talked at length about odds, survival rates, disease progression, etc. I'll paraphrase what I believe he said. His bottom line, if I can avoid aggressive treatment for a period of time, or forever, and then avoid reasonable risk of deleterious side effects, than this is a useful choice.

His conclusions currently are that likelyhood of low-grade / early stage cell differentiation like I have, turning into aggressive PCa is quite low. This is well supported by long-term studys and outcomes (death rates) from PCa. In fact, there looks to be an emerging school of thought these days across researchers that formation of aggressive cancer in patients like me could in fact be a separate event entirely -- i.e. happens independently ... there is low likelyhood that differentiated cells in Gleason 3+3 or 3+4 patients will evolve further to higher grades of aggressiveness.

If that is the case, AS monitoring is the right choice, as we'll then find aggressive stage if or when it should occur. And low grade stage as I have now will very likely NOT cause any other metastatic issues now or later.

So, how do we implement effective AS? San Antonio center, as well as a number of others across the country are participating now in a long term Canary Foundation study of Active Surveillance. I will enroll with them in this study. I will trust that this will keep track of my status effectively.

I'll "officially" start in the study next spring when I go in for next followup appointment (frequency every 6 mos with Dr. Thompson). I have the written summary from them however, and can describe all of the steps and schedules in separate thread if that is of interest.

Other study points -- there are 730 registered participants in San Antonio alone, and there are 8-10 other sites in US. The principal point of study as I understand it is to find the "right" biological markers that effectively predict aggressive PCa, vs. low level cell differentiation only that will very likely never result in metastatic effects. I think a principal focus now is on urine tests and markers. Dr. Thompson specifically said that they are actively pursuing tests that minimize or eliminate need for biopsy and repeat biopsy -- which sounds GREAT to me :)

I can advise more about Canary study as I get into it further. Otherwise, with current (July) PSA level back to 3.4, I'm happy now to watch and wait.
Congratulations on your treatment plan. I think that AS sounds like a great plan for you. How great would it be if you can go through your youngish years as well as your older ones without having to suffer the side effects of treatment.

AS programs I have seen all have the same basic elements but differ slightly on the timing. PSAs, DREs, and biopsy are always included. Biopsies vary from annual (Johns Hopkins) to a repeat at about a year followed by another every few years or if indicated. Some will include periodic imaging. Some include biomarkers like PCA3, TMPRSS2:ERG fusion, free PSA and PHI.

One unknown is what is the best trigger to come off AS. Some think Gleason 4+3; some think PSADT<3 yrs; some think it should be based on tumor volume.

I'd be interested in seeing your protocol when you get around to posting it.

- Allen
Finally have time to describe what I've been learning about AS protocol in the PASS study. I have a preliminary screening (intake?) appointment on Oct 18th, and will advise of anything further that I learn.

UTSA and Canary PASS Study Protocol. This is description that I'm initially finding, apologize for lengthy post:

Visit 1 - screening
- medical history, exam and extended DRE and urine sample
- blood draw for PSA, serum, plasma, white cells
- biopsy if prior unavailable, or less than 10 cores, or if biopsy and diagnosis was more than 1 year ago
- food questionnaire, supplements use questionnaire, quality of life (QOL) questionnaire

Review of all screening exams, tests, procedures to determine if participate in study - researcher will discuss all with patient as well as other possible options.

Visit 2 - month 3

Visit 3 - month 6
- medical history review, physical exam with extended DRE and urine sample
- blood draw for PSA, serum, plasma
- QOL questionnaire

Visit 4 - month 9

Visit 5 - month 12
- medical history review, physical exam with extended DRE and urine sample
- blood draw for PSA, serum, plasma
- QOL questionnaire

Visit 6 - month 15

Visit 7 - month 18
- medical history review, physical exam with extended DRE and urine sample
- blood draw for PSA, serum, plasma
- QOL questionnaire

Visit 8 - month 21

Visit 9 - month 24
- medical history review, physical exam with extended DRE and urine sample
- blood draw for PSA, serum, plasma
- QOL questionnaire

Visits 10+
- repeat cycle until month 60, or study termination

Additionally ....
Study defines repeat biopsy at 6-12 months from study entry, and then every 2 years.

They further advise in protocol that, should cancer progress at any time during AS, the study doctor will discuss treatment options. Participation is at all times voluntary, and we can withdraw at any time.

In discussion last month with Ian Thompson, he and team are actively pursuing strategies to reduce or eliminate need for repeat biopsies. But current protocol is every two years.

We didn't yet talk about details around biopsy alternatives or how close they might be to confirming urine testing strategy vs. biopsy. My view ... we have all been hearing about this idea, but it is still a long ways off until we have biopsy alternative strategies confirmed. I'll inquire further at my 10/18 appointment and advise of anything new that I learn.

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