Originally published 8/2/2018
The circumstances behind this update are unusual. Fourteen months prior to the time of this writing, the world began locking down due to the emerging SARS-CoV-2 viral pandemic and the potentially deadly COVID illness it causes. Over the ensuing year, restrictions such as masking and social distancing, and the closing of businesses deemed nonessential, waxed and waned depending on the number of positive tests and new diagnoses. We were all confused, and studies repeatedly show that normal screening for cancers such as breast, prostate and colorectal dropped significantly. Many people, including those who had been newly diagnosed with cancer before the lockdowns occurred, simply did not feel safe going into their doctors’ offices.
While the original blog below focused on Active Surveillance as an informed, monitored strategy to delay radical treatment for prostate cancer (PCa), the pandemic-related avoidance of cancer screenings was not an informed choice. It was the result of fear and anxiety, but as restrictions are relaxing thanks to COVID vaccines, visits to the clinic and testing facilities are once again picking up. An April, 2021 study explores the consequences of COVID-related absence from care for newly diagnosed cancer patients in France.[i] The study projected a possible excess number of cancer deaths in the coming years.
Is it safe to delay treatment after prostate cancer treatment in the midst of a pandemic? Data was drawn from a nationwide network of cancer care centers. In the first 7 months of 2020, visits by newly diagnosed patients dropped 6.8% compared with the same period in 2019. This drop was greatest, at 21%, during the height of the lockdown in April and May; this decrease did not pick up until November. “The reduction was more pronounced in women, in breast and prostate cancer, and for patients without metastasis.” In other words, newly diagnosed prostate cancer (PCa) patients with non-metastatic disease were delayed at least 8 months in picking up care and treatment decisions.
While the authors based their projection of a future 1000-6000 excess deaths on a mathematical extrapolation, the point is well taken. It is NOT safe to delay PCa treatment—or breast and colorectal cancers—in conditions where further diagnostic evaluation and access to treatment as needed cannot be obtained because patients don’t show up. This sheds light on the importance of following up quickly on thorough diagnosis that included MRI and targeted biopsy. And, if the informed decision is to delay treatment, do it with responsible, well-monitored active surveillance.
You’ve just had a prostate biopsy, and you’re waiting for the results. You figure you’ll get a head start on researching your options. As you surf the internet, and watch YouTube videos, you encounter a lot of information on radical prostatectomy, several forms of radiation including proton beam and seed implants, and perhaps less material on focal treatments. You’re trying to be open-minded and somewhat rational as you jot down questions that come to mind. You also learn that Active Surveillance is increasingly recommended to men newly diagnosed with low-risk prostate cancer (PCa). “Gosh,” you say to yourself, “I sure hope I don’t have prostate cancer, but if I do, I can only hope it’s low risk and I can go on Active Surveillance. That way I can put off treatment so I don’t have to deal with side effects.”
Active Surveillance (AS) is on the rise for two basic reasons. First, the use of multiparametric MRI (mpMRI), targeted biopsy, and biomarkers qualifies AS candidates with greater confidence. Second, we now realize that untold thousands of men with low-risk PCa have been over-treated, leaving them with urinary and sexual problems as a trade-off in the quest for a cure.
Is it safe to wait?
A 2015 study published by University of Chicago researchers concluded that men diagnosed with low-risk PCa “… may safely use the time following their initial biopsy to consider management options and obtain a restaging biopsy, if recommended,” for up to a year without raising risk of recurrence.[ii] And yet, 45% of the total 17,943 low-risk cases in their study were found to have adverse pathology (worse disease) at the time of surgery! Here are the timeframes:
- 16,818 patients had surgery within 6 months of diagnosis
- 894 had surgery at 6-9 months
- 169 had surgery at 9-12 months
- 62 had surgery at over 12 months.
Since all patients presumably had TRUS biopsy, which misses PCa roughly 30% of the time, I believe some diagnoses were underestimated to begin with. Still, with nearly half of cases ending up with higher grade, higher stage, or lymph node involvement at the time of surgery, how did the authors interpret that it is safe to use up to 12 months to “consider management options”?
Not so safe after all
A 2018 paper presented at the 33rd European Association of Urology Congress (Copenhagen, Denmark) underscores my concern. This was a much smaller study of 513 men at a single French medical center. The authors found that for patients with Gleason 3+4 PCa, a 90 day delay from biopsy to prostatectomy significantly increased their risk of biochemical recurrence (meaning a detectable or rising PSA after surgery, when PSA should drop to zero) vs. those who had surgery sooner.[iii] (They did not, however, identify a time threshold for Gleason 3+3 patients.)
It’s hard to compare both studies since the more recent one divided patient groups by Gleason grade. Nonetheless, I believe both studies cast doubt on the safety of Active Surveillance as a way to delay treatment if conventional TRUS biopsy and monitoring by PSA and repeat biopsy are used.
A better way
Let me approach this differently. Rather than ask, “Is it safe to delay treatment after prostate cancer diagnosis?” I would pose the question, “How can we make it safer to delay treatment after prostate cancer diagnosis?” The answer is, change the diagnosis and monitoring protocol. Instead of TRUS biopsy, PSA tracking, and repeat TRUS biopsy, at our Center we offer
- Baseline multiparametric MRI before biopsy to detect any suspicious area(s)
- In-bore MRI-guided targeted biopsy for the most accurate tissue diagnosis with the fewest needles
- Advanced diagnostics, including genomic/biomarker analysis if indicated
- If a patient is diagnosed with low-risk disease, use of mpMRI plus PSA tests to monitor
- Repeat in-bore targeted biopsy only if PSA and imaging detect tumor growth or progression toward aggressiveness
Finally, if growth or progression triggers a treatment decision, for qualified patients we offer Focal Laser Ablation (FLA) to treat the known cancer (plus a margin of safety). FLA is a treatment approach that tailors a cancer-destruction method to the tumor, with minimal-to-no risk of disrupting urinary and sexual function. In other words, we control the cancer without over-treating the disease.
Thus, the Sperling Prostate Center not only offers the safest way to delay treatment, but also preserves a patient’s dignity and manhood if treatment is needed.
Contact us to learn more about mpMRI for prostate cancer detection, diagnosis and treatment.
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NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[i] Blay JY, Boucher S, Le Vu B, Cropet C et al. Delayed care for patients with newly diagnosed cancer due to COVID-19 and estimated impact on cancer mortality in France. ESMO Open. 2021 Apr 17;6(3):100134.
[ii] Weiner AB, Patel SG, Eggener SE. Pathologic outcomes for low-risk prostate cancer after delayed radical prostatectomy in the United States. Urol Oncol. 2015 Apr;33(4):164.e11-7.
[iii] Charnow, Jody. “Biopsy-to-RP delay may up prostate cancer recurrence risk.” Renal & Urology News, Mar. 26, 2018. https://www.renalandurologynews.com/eau-congress/biopsy-prostate-surgery-biochemical-recurrence/article/753581/
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
