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    Old 01-04-2020, 05:42 AM   #1
    DjinTonic
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    Long-term outcomes of active surveillance at MSK

    Long-Term Outcomes of Active Surveillance for Prostate Cancer - The Memorial Sloan Kettering Cancer Center Experience [2019]

    https://www.ncbi.nlm.nih.gov/pubmed/31868556

    Quote:
    ...
    MATERIALS AND METHODS: 2,907 patients were managed with AS between 2000-2017 of whom 2,664 were Grade Group 1.
    ...
    RESULTS:
    The median age at diagnosis was 62 years. For men with Grade Group 1 prostate cancer, the treatment-free probability at 5, 10, and 15 years was 76% (95% CI 74%-78%), 64% (95% CI 61%-68%), and 58% (95% CI 51%-64%), respectively. At 5, 10, and 15 years, there were 1,146, 220, and 25 men at risk for metastasis, respectively. The median follow-up for those without metastasis was 4.3 years (95% CI 2.3-6.9). Five men developed distant metastasis. Upon case note review, only two of these men were deemed to have disease that could have been cured on immediate treatment. The risk of distant metastasis was 0.6% (95% CI 0.2%-2.0%) at 10 years.

    CONCLUSIONS:
    AS is a safe strategy over longer follow-up for appropriately selected patients with Grade Group 1 following a well-defined monitoring plan.
    Another consoling study:

    OUTCOMES OF RADICAL PROSTATECTOMY AFTER A PERIOD OF ACTIVE SURVEILLANCE [2019]

    https://www.auajournals.org/doi/abs/10.1097/01.JU.0000556454.14355.9d

    Quote:
    ...
    Of 1,812 men enrolled in AS between 1994 and 2016, 431 (23.8%) underwent deferred RP. Median time to RP was 26 months (IQR 15-46). At diagnosis, 378 men (87.7%) had GS 3+3 disease, 25 men (5.8%) had GS 3+4 disease with one high grade core, and 28 men (6.5%) had GS 3+4 with two or more high grade cores.
    ...
    CONCLUSIONS:
    The majority of patients undergoing deferred RP after a period of AS did not have any adverse features at the time of surgery. Our results support the careful use of AS in men with GS 3+4 and one high grade core at diagnosis. Men with GS 3+4 and two or more high grade cores at diagnosis had a significantly greater risk of recurrence, and likely benefit from immediate treatment.
    [Emphasis mine]

    Djin

     
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    Old 01-04-2020, 06:26 AM   #2
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    Re: Long-term outcomes of active surveillance at MSK

    Thanks, DJin, those statistics are similar to Johns Hopkins. More good news😀
    I did not realize that MSKCC’s enrollment was that large.

    I would like to see a similar report on the Grade Group 2 results, as that issue remains unclear.

     
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    Old 01-04-2020, 06:45 AM   #3
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    Re: Long-term outcomes of active surveillance at MSK

    The majority of men....

    Then there is my brother; 6 cores G6 and one core 3+4. Failed surgery with a 0.03 going to 0.05 in 3 months followed by ADT and radiation.

    I am failing to understand the need to keep one's prostate in the face of a cancer risk. Everything seems to be working just fine without it.

     
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    Old 01-04-2020, 06:56 AM   #4
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    Re: Long-term outcomes of active surveillance at MSK

    Quote:
    Originally Posted by Prostatefree View Post
    The majority of men....
    _
    Then there is my brother; 6 cores G6 and one core 3+4. Failed surgery with a 0.03 going to 0.05 in 3 months followed by ADT and radiation.

    I am failing to understand the need to keep one's prostate in the face of a cancer risk. Everything seems to be working just fine without it.
    There are risks of poor outcomes of treatment (ED and urinary), some very poor. Many men who are good AS candidates (which do not include your brother's biopsy status) never need treatment. That's a big plus. And if they do, there is a good chance the delay causes no increased risk.

    I, for one, am a strong advocate of someone making as sure as possible they are a good candidate before embarking on AS, including a genomics test.

    Everything doesn't work just fine after treatment for some men.

    However, AS candidates are free to treat immediately, too. Docs can present the pros and cons.

    Djin

     
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    Old 01-04-2020, 07:22 AM   #5
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    Re: Long-term outcomes of active surveillance at MSK

    Quote:
    Originally Posted by Prostatefree View Post
    The majority of men....

    Then there is my brother; 6 cores G6 and one core 3+4. Failed surgery with a 0.03 going to 0.05 in 3 months followed by ADT and radiation.

    I am failing to understand the need to keep one's prostate in the face of a cancer risk. Everything seems to be working just fine without it.
    I would never advise a man with your brother’s pathology to do AS. There are criteria used at all the AS programs, and he would not have qualified for any of them.

    You are fortunate if “everything is working fine”. I have read hundreds (thousands?) of posts across the Internet, and heard men in local groups, complaining that their quality of life had been ruined by (possibility unnecessary) surgery.

    Just my experience....

     
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    Old 01-04-2020, 08:47 AM   #6
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    Re: Long-term outcomes of active surveillance at MSK

    Quote:
    Originally Posted by Prostatefree View Post
    The majority of men....

    Then there is my brother; 6 cores G6 and one core 3+4. Failed surgery with a 0.03 going to 0.05 in 3 months followed by ADT and radiation.

    I am failing to understand the need to keep one's prostate in the face of a cancer risk. Everything seems to be working just fine without it.

    I am glad to hear that your operation turned out tremendous for you.

    However, not everyone has the same experience, as prostatectomy is a technically challenging procedure with a fairly high degree of serious side effects.

    Add that fact, to the other idea that a majority of men eventually get prostate cancer and the majority of those cases the cancers are quite indolent, the idea of surveillance in at least some cases becomes more realistic.

     
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    Old 01-04-2020, 09:26 AM   #7
    IADT3since2000
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    Cool Re: Long-term outcomes of active surveillance at MSK

    Adding the Toronto experience to this thread (and lower age eligibility)

    Dr. Laurence Klotz, MD, arguably the world's leading AS guru (and a leader in so many other areas of prostate cancer during a brilliant career), wrote this article, "Contemporary approach to active surveillance for favorable risk prostate cancer", which was published in the print version of the Asian Journal of Urology in April 2019 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488691/, which is available in full electronically). He describes results for his very large and very long-running AS group of patients in the context of other major AS programs, with special attention to the program at Johns Hopkins. Success is very similar to the impressive results described earlier in this thread.

    However, the Klotz team took arguably the most liberal approach, including a substantial proportion of GS-7 patients, in sharp contrast to the fairly restrictive approach at the other end of the spectrum, run by Dr. H. Ballentine Carter, MD, at Johns Hopkins. In essence, Dr. Klotz, growing a bit more conservative based on their experience, now feels that doctors and patients need to be more cautious about GS-7 patients entering active surveillance, while Johns Hopkins has liberalized a bit, certainly regarding managing younger patients on AS, and, I believe but without direct knowledge, shifting from annual biopsies to a more widely spaced follow-up pattern.

    The cited paper, one of many by Dr. Klotz on AS, had this one thought in section 2.2 on patient eligibility that I considered particularly interesting and counter-intuitive: "If highergrade cancer can be excluded in a patient with higher volume Gleason score 6 cancer (based on magnetic resonance imaging [MRI], targeted/template biopsies, and/or biomarkers), such patients are unlikely to require treatment." Wow! He then added: "In rare instances, men under 55 years old present with extensive Gleason score 6 cancer. In these unusual cases, radical intervention, such as surgery, may be appropriate." Also notable, his team has found that MRI (probably mpMRI) IS useful in determining AS eligibility in part because of its ability to reveal large significant prostate cancers in the anterior zone, which is somewhat at odds with other research I have seen, but may be reconcilable because of the size of the tumors, with the other research perhaps relating more to smaller significant tumors.

    I was able to interact directly with Dr. Klotz at a major research conference on prostate cancer by asking his panel an audience question regarding whether age was an eligibility factor for AS. This was back in 2007, just five years after publication of the first paper on AS, at the conference to review research sponsored by the Prostate Cancer Research Program under the auspices of the Congressionally Directed Medical Research Program. I was one of about 100 patients/grant proposal reviewers along with around 900 medical reviewers and experts on prostate cancer.

    The plenary session panel included: Dr. Fritz Schroeder, another early and leading pioneer of AS, from Erasmus University Rotterdam, The Netherlands; Dr. Stephen Freedland, then from Johns Hopkins; Dr. Christopher Warlick, recently from Johns Hopkins; Dr. Klotz of U. of Toronto, Sunnybrook, and Robert Carey (patient?), with Dr. Christopher Logothetis, the then very well known researcher/urologist from MD Anderson Cancer Center in Houston.

    My question to the panel was the lower age limit they used for eligibility for AS, with most programs at the time using a lower limit of around 60 to 65, which was echoed by the first three doctors. Then Dr. Klotz, who is tall and has a commanding presence, rose, stating that he believed there should be no lower age limit and gave a brief rationale. That wasn't what I or probably almost anyone else in the room expected. You could have heard a pin drop in that large conference room! These days, his view has prevailed, and my impression is that there are no age limits for major programs.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

    Last edited by IADT3since2000; 01-04-2020 at 09:26 AM. Reason: Minor typo

     
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    Old 01-04-2020, 09:40 AM   #8
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    Re: Long-term outcomes of active surveillance at MSK

    I don't remember any age restrictions in a study that listed and compared the criteria for AS at the major institutions.

    I asked my uro what program he follows for his AS patients. He said his criteria are probably closest to JH's, probably the strictest. He said some of the other programs are "pretty loosey goosey" (his words). He makes use of genomic testing, which he finds especially useful for G7 (3+4). My doc said he uses both Decipher and OncotypeDx for biopsy-tissue testing, but prefers OncotypeDx, not because he thinks it any more reliable, but because he finds the results presented in a way that's more useful -- probably from the viewpoint of patient comprehension. -- just one uro's view.

    I've followed Dr. Klotz's work since my diagnosis.

    Djin

     
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    Old 01-04-2020, 10:10 AM   #9
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    Re: Long-term outcomes of active surveillance at MSK

    Quote:
    Originally Posted by ASAdvocate View Post
    .....I have read hundreds (thousands?) of posts across the Internet, and heard men in local groups, complaining that their quality of life had been ruined by (possibility unnecessary) surgery.
    ...same can be said for radiation. There are no silver bullets.
    __________________
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    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    Second 3T MRI 1/17
    RALP 7/17, G3+4, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over next 4 months
    DCFPyl PET & ercMRI @NCI - 11/17
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    Old 01-04-2020, 10:18 AM   #10
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    Re: Long-term outcomes of active surveillance at MSK

    Quote:
    Originally Posted by IADT3since2000 View Post
    Adding the Toronto experience to this thread (and lower age eligibility)

    Dr. Laurence Klotz, MD, arguably the world's leading AS guru (and a leader in so many other areas of prostate cancer during a brilliant career), wrote this article, "Contemporary approach to active surveillance for favorable risk prostate cancer", which was published in the print version of the Asian Journal of Urology in April 2019 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488691/, which is available in full electronically). He describes results for his very large and very long-running AS group of patients in the context of other major AS programs, with special attention to the program at Johns Hopkins. Success is very similar to the impressive results described earlier in this thread.

    However, the Klotz team took arguably the most liberal approach, including a substantial proportion of GS-7 patients, in sharp contrast to the fairly restrictive approach at the other end of the spectrum, run by Dr. H. Ballentine Carter, MD, at Johns Hopkins. In essence, Dr. Klotz, growing a bit more conservative based on their experience, now feels that doctors and patients need to be more cautious about GS-7 patients entering active surveillance, while Johns Hopkins has liberalized a bit, certainly regarding managing younger patients on AS, and, I believe but without direct knowledge, shifting from annual biopsies to a more widely spaced follow-up pattern.

    The cited paper, one of many by Dr. Klotz on AS, had this one thought in section 2.2 on patient eligibility that I considered particularly interesting and counter-intuitive: "If highergrade cancer can be excluded in a patient with higher volume Gleason score 6 cancer (based on magnetic resonance imaging [MRI], targeted/template biopsies, and/or biomarkers), such patients are unlikely to require treatment." Wow! He then added: "In rare instances, men under 55 years old present with extensive Gleason score 6 cancer. In these unusual cases, radical intervention, such as surgery, may be appropriate." Also notable, his team has found that MRI (probably mpMRI) IS useful in determining AS eligibility in part because of its ability to reveal large significant prostate cancers in the anterior zone, which is somewhat at odds with other research I have seen, but may be reconcilable because of the size of the tumors, with the other research perhaps relating more to smaller significant tumors.

    I was able to interact directly with Dr. Klotz at a major research conference on prostate cancer by asking his panel an audience question regarding whether age was an eligibility factor for AS. This was back in 2007, just five years after publication of the first paper on AS, at the conference to review research sponsored by the Prostate Cancer Research Program under the auspices of the Congressionally Directed Medical Research Program. I was one of about 100 patients/grant proposal reviewers along with around 900 medical reviewers and experts on prostate cancer.

    The plenary session panel included: Dr. Fritz Schroeder, another early and leading pioneer of AS, from Erasmus University Rotterdam, The Netherlands; Dr. Stephen Freedland, then from Johns Hopkins; Dr. Christopher Warlick, recently from Johns Hopkins; Dr. Klotz of U. of Toronto, Sunnybrook, and Robert Carey (patient?), with Dr. Christopher Logothetis, the then very well known researcher/urologist from MD Anderson Cancer Center in Houston.

    My question to the panel was the lower age limit they used for eligibility for AS, with most programs at the time using a lower limit of around 60 to 65, which was echoed by the first three doctors. Then Dr. Klotz, who is tall and has a commanding presence, rose, stating that he believed there should be no lower age limit and gave a brief rationale. That wasn't what I or probably almost anyone else in the room expected. You could have heard a pin drop in that large conference room! These days, his view has prevailed, and my impression is that there are no age limits for major programs.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.
    Just one point to add to this informative post. The issue of biopsies under-sampling the anterior region of the prostate has been addressed with the Precision Point transperineal system, that has now been implemented at NIH and Johns Hopkins, with more centers following.

     
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    Old 01-04-2020, 10:21 AM   #11
    DjinTonic
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    Re: Long-term outcomes of active surveillance at MSK

    It will be both interesting and important to see if future AS show correlations between genomics testing and AS outcomes.

    Djin

     
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    Old 01-04-2020, 12:18 PM   #12
    Southsider170
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    Re: Long-term outcomes of active surveillance at MSK

    Quote:
    Originally Posted by DjinTonic View Post
    It will be both interesting and important to see if future AS show correlations between genomics testing and AS outcomes.

    Djin

    Its always a possibility that we will never find out. Example given, if an injection were developed to cure most cases of PC systematically, AS may be irrelevant if the cure becomes a lot easier.

    Or if genomic testing were refined enough that indolent and risky cases could be accurately forecast.

     
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