PROSTATE CANCER WATCHFUL WAITING

Jon Nowlin has done a good deal of research in coming to grips with his options following his diagnosis. He has summarised some of the key criteria from various studies in a Table, which is set out below. The published studies from which he has extracted the data are linked.

If the subject of Active Surveillance is new to you, it would probably be help if you read Active Surveillance: towards a new paradigm in the management of early stage prostate cancer, a Review article published in The Lancet in February 2004.

 

REVIEW OF SOME ONGOING
ACTIVE SURVEILLANCE PROGRAMS
Dated August 2006
Critera for Active Surveillance Programs	Prostate Forum Sept. 1998	Carter et al, 2002	Schroder et al 2003 (proposed criteria)	Choo et al, 2004	Klotz, 2005	Hardie et al, 2005	Johns Hopkins Grady Inst. 2006	Kakehi et al, 2006	Loblaw et al, 2006	Roemeling et al, 2006
	(review)	Johns Hopkins	Rotterdam	Sunny brook Toronto	Sunny brook Toronto	Royal Marsden	Johns Hopkins	Japan Kagawa Med.U.	Sunny brook Toronto	Rotterdam
SELECTION FOR ACTIVE SURVEILLANCE
Age	> 70		< 75	49-84			>= 60	50-80
Life Expectancy			> 10
Confirmation biopsy required?	no	no		no		no	yes
Stage	T1C	T1c	T1c - T2a	T1b - T2b	T1c - T2a	T1/T2	T1C	T1c	T1C - T2	T1C - T2
Needle cores positive		<= 2	1				<= 2	<= 2	<=3	<=2
% of + core		< 50%	< 30%				< 50%	< 50%	<50%
Gleason	<= 6	<= 6	<= 6, no 4	<= 7	<= 6	<= 7	<= 6	<= 6	<= 6	<=6
Initial PSA			5 - 8	< 15	< 10	<= 20		<= 20	<= 10	<= 15
PSA Density		< 0.15	< 0.1				< 0.1			<0.2
PSA Doubling, years	> 5
Free PSA			<= 19%				> 10 - 15 %
MONITORING PROGRAM
PSA and DRE		Every 6 months	Every 3 month	Every 3 months for 2 years, then every 6 months.	Every 2 months	Every 3 months for 2 years, then every 6 months.	Every 6 months
TRUS				6 mo
Repeat biopsy		12 mo	12 mo	18 mo	2, 5, 10 yr	not routine	12 mo
Bone Scans				12 mo
CRITERIA FOR TREATMENT
PSA				> 8
PSADT			< 2	< 2	<=  3	See Note below			"rapid"
Needle cores positive		> 2					> 2
% of + core		. 50%					. 50%
Gleason		ind. 4 or 5	increase or subscore 4	>= 8			ind. 4 or 5		Grade progression
TREATMENT
		Radical Prostatectomy	Patient Request	Radical Prostatectomy		Hormone	Radical Prostatectomy

Note: Individual analysis: assumes PCA does not become systematic until PSA >=50  Estimate life expectancy, then calculate maximum PSDT rate by time for initial PSA to reach 50.  The RoyalMarsden policy is to use an individualized threshold for each patient, depending on absolute PSA level and life-expectancy (from actuarial tables), and assumes that low-grade prostate cancer seldom becomes symptomatic before the serum PSA level reaches 50 ng/mL. For example, a man with a PSA level of 6 ng/mL needs three PSA doublings before his PSA reaches 50 ng/mL. If his life-expectancy is 10 years, then his PSADT threshold will be ª 3 years. However, if his life-expectancy were 20 years, then a threshold of 7 years would be more appropriate. In practice, the choice of PSADT threshold is an exercise in shared decisionmaking and is influenced by the relative importance that the patient places on treatment side-effects against possible improvements in longevity.

RATIONALE : MY EXPERIENCE : PSA 101: MY PSA : ACTIVE SURVEILLANCE : OBJECTIFIED OBSERVATION