Chief of Urology at MSKCC: Active Surveillance as Treatment for Prostate Cancer Is Effective but Underused

If you are newly diagnosed with a localized, low-grade prostate cancer (generally a Gleason score of less than 7, a PSA of 10 or less, stage T1c, etc.), I suggest you read this comprehensive slide presentation on “Active Surveillance” (previously called “watchful waiting”), by Dr. Peter Scardino, chief of Urology at Memorial Sloan Kettering Cancer Center.  Contrary to what some people think, AS is not doing nothing. Patients receiving AS are carefully monitored to detect potential progression of their PC. One useful tool is repeat biopsies. Their predictive value is discussed extensively in this presentation.

What I find interesting about Dr. Scardino is that, although he is a surgeon by training who does a lot of radical prostatectomies, he is also a strong advocate of AS for low-risk patients. Dr. Scardino does not reflexively reach for his scalpel. He is just as likely to reach for his “nomograms”, formulas which attempt to predict the likelihood of progression of indolent, or slow-growing, prostate cancer (most PCs fit into this category), using a broad variety of patient data.

The key to using AS successfully is to home in on the small percentage of low-grade prostate tumors which WILL become life-threatening. The holy grail of PC research is a biomarker(s) that will eventually allow physicians to separate the “good” cancers from the “bad.” A lot of smart people are working on this, but in the meantime we have to rely on the tools we have. Dr. Scardino’s nomograms are accurate about 75% of the time.

There are some surprises in the AS presentation: for example, Dr. Scardino says that it is the number of cores with prostate cancer and amount of cancer in those cores, as revealed by the patient’s biopsy, rather than PSA doubling time, that correlate most with cancer progression.  Obviously, the more cancer there is, the higher the chance of an aggressive tumor.

Dr. Scardino’s nomograms are user-friendly. You should always get copies of your medical records anyway, and study them carefully. Then, if you choose, you can plug in the relevant data (if you have a question, ask your doctor) and you will get a pretty good idea whether you are a candidate for AS or not.

The problem with AS now is that it is often not even presented to patients as an option.  Doctors who treat prostate cancer feel compelled to do invasive treatments for various reasons — number one is that they are afraid they will miss that rare cancer that will become life-threatening. I believe, as does Dr. Scardino, that this needs to, and will change.  Performing 50 surgeries to save one life may be a worthwhile goal, but saving that one person can be done without leaving 49 other men with nasty side effects like impotence and incontinence.  Surgery is the right treatment for many PC patients, especially those with intermediate- or high-grade cancer (some doctors do not perform prostatectomies on high-risk patients), but it should be used sparingly, when all other options have been ruled out. Many surgeons downplay the potential side effects of radical prostatectomy (especially when performed by the robot), but believe me, RP can make a big dent in your quality of life.

Active surveillance has not taken root in this country as it has in Europe and other places.  Maybe this is because no man wants to be the first person to receive a particular treatment or even to be part of a small group receiving the therapy. But I predict that, as the facts become known and a critical mass of men in this country opt for AS, other PC patients will feel more comfortable with the treatment.

At present many men who are interested in AS encounter obstacles. Some cannot find a doctor who is willing to go along with their preference.  Others who choose AS are disparaged by their peers as “cowards.” In fact it is THEY, and not the patients who have undergone surgery, who suffer most from anxiety.  I say we are waging a war on two fronts: one on prostate cancer, and another, in FDR’s words, on “fear itself.” Perhaps presenting a comprehensive review of the research on active surveillance, as Dr. Scardino does, will help allay some of these fears and will allow many to keep their bodies and functions intact AND to remain cancer-free at the same time.

Dr. Scardino’s presentation is available courtesy of Urotoday.com. You can sign up for their free daily updates on PC, erectile dysfunction and other interesting topics. That’s my favorite read — can’t start my day without my “UroAlert.”

Here is the link to Dr. Scardino’s presentation:
http://tinyurl.com/yfpajug