Prostate cancer: Over-diagnosis and active surveillance.

In February of this year the Prostate Cancer Research Institute (PCRI) published a Q&A interview discussing an approach to prostate cancer with Dr. Laurence Klotz, who is a professor in the Department of Surgery at the University of Toronto.

Here is a link to the article in PCRI Insights:
Active Surveillance: Q&A with Dr. Laurence Klotz.

This was of more than passing interest to me because this was exactly the approach that I followed on the advice of my  urologist. I was first referred to him when my PSA levels started to trend up and my GP became concerned. I had a number of PSA tests at 6-monthly intervals and a couple of biopsies thrown in, but no actual cancer was found until the third or fourth biopsy.

When cancer was eventually found it was identified as "low-grade" and "slow-growing". The urologist explained that, clinically, there was no indication that it should be treated in any way and that if it stayed that way I would eventually die with prostate cancer but not die because of it. He cautioned that the cancer could change and then the scenario would need to be handled differently. Meanwhile he counselled "active surveillance" with 6-monthly PSA tests, annual DRE and a biopsy every 18 months.

This situation continued 5 years and I began to get used to the idea of being in perfect health other than having a touch of cancer. Alas, it was not to last. PSA's began to rise and a biopsy came back with the news that the cancer had kicked up a notch on the Gleason aggressiveness scale. I chose to have my prostate removed rather than take the radiation route. I am experiencing some of the unpleasant consequences of having had a prostatectomy, but I am also grateful that I had five extra years with my prostate with which I was very attached. A decade or even just five years earlier and it would have been removed at the first detection of the dreaded "C".

The interview with Dr Laurence Klotz.

Following are the first few paragraphs of the interview.

What is active surveillance, and how does it compare with other methods of treating prostate cancer?

Dr L Klotz

The concept of conservative management for prostate cancer is not new. In fact, in Scandinavia and England in the 70s, basically no one was treated until they had metastatic disease. And the idea was that treatment didn’t really have much effect; this was a slow-growing disease and people didn’t die from it. We now know that is wrong in many respects, and so the idea of no treatment has pretty much been abandoned.

When PSA emerged around 1989, and suddenly all this early prostate cancer was being diagnosed, the idea was that many of these patients harbored aggressive disease and should be treated radically. And virtually all newly diagnosed men in the United States, Canada and most of the Western world were offered aggressive treatments for their disease.

But not everyone with prostate cancer is destined to die from it, and the real problem with PSA screening that should be addressed is the over-diagnosis of clinically insignificant disease.

The crux of the problem is that the likelihood of harboring small bits of prostate cancer in a man is about equal to his age as a percentage. So that means in men who are, say, between 50 and 70 - which is the key age group for diagnosing and treating prostate cancer - somewhere around 60 percent will have small bits of prostate cancer. And many of them will have an elevated PSA, due, for example, to benign prostatic enlargement. This leads to a biopsy, and the biopsy finds these little bits of prostate cancer. And these patients were all getting radical treatment, even though what they had was (in my view) really part of the aging process, something that develops more or less normally in men with age.

The active surveillance was an attempt to grapple with this by saying, okay, we know that guys who have bad prostate cancer need treatment, and benefit from it. And that’s been clearly shown in randomized trials. But the patients dying of prostate cancer tend to have higher grade (Gleason) cancer. So maybe we can take the ones who have low-grade cancer, just manage them conservatively, and keep a close eye on them because some may develop something worse. We can then treat those who get reclassified as having higher risk disease, and observe the rest.

Read the rest of the interview here: 
Active Surveillance: Q&A with Dr. Laurence Klotz.