If you were a healthy 77-year old man in 2014, you would be expected to have an average of 9.93 years of life remaining, according to the U.S. Social Security Actuarial Life Table.[i] If your health wasn’t so great – let’s say you had diabetes or you were a smoker – your life expectancy would be shorter. And yet, if you were 77 in 2014 and were diagnosed with Gleason 3 + 3 prostate cancer, there’s a very good chance that you would have been recommended for aggressive treatment (prostatectomy or radiation).
This reality was brought home by a 2014 study of over 96,000 cases of men aged 66 and older who were diagnosed with prostate cancer (PCa) less than or equal to Gleason 7.[ii] Among those age 75-79 who had a life expectancy less than 10 years, over half (57%) had aggressive treatment anyway. Keep in mind that by today’s standards, Gleason 3 + 3 would most likely be considered insignificant. Even younger men today with 20+ years of life expectancy are offered Active Surveillance for Gleason 3+3 as an alternative to aggressive treatment.
Thus, as recently as four years ago, untold thousands of men with insignificant PCa and less than 10 years life expectancy were overtreated, often with harsh consequences. The study noted, “Because of their low likelihood of 10-year survival, these men are unlikely to live long enough to substantially benefit from aggressive treatment, but they incur its associated side effects and financial burden.”
The tide is turning
Now, a mere four years later, the need for such over-treatment is rightly being questioned. Evolving diagnostic technologies (multiparametric MRI and improved biomarker tests) are more accurately revealing how many newly diagnosed men have insignificant PCa that qualifies either for surveillance or a less aggressive treatment such as Focal Laser Ablation (FLA).
In fact, a new study brings encouraging news. It appears that aggressive treatment, particularly prostatectomy, is more appropriately being done for patients with significant disease. Witherspoon, et al. (2018) retrospectively studied 1,897 patients who had prostatectomy over a six year period from 2009 to 2015.[iii] The authors wrote that “…randomized and observational studies have improved our knowledge regarding the natural history of low-risk prostate cancer, and it is now well accepted that most low-grade cancers are associated with minimal risk of cancer-related death.” The Witherspoon study’s numbers confirm that indeed, clinical practice is changing because of this: “The proportion of patients who had intermediate- or high-risk disease [that was treated aggressively], based on National Comprehensive Cancer Network criteria, rose from 46.7% in 2009 to 90.2% in 2015.”[iv]
While the Witherspoon study was restricted to medical records in Eastern Ontario, Canada, it was noted that research from the U.S. and Europe also suggest a trend toward treating insignificant PCa with a light touch. Thus, the treatment tide is starting to turn.
Active surveillance or focal therapy?
Today, both Active Surveillance and focal treatments are on the rise. In terms of clinical factors, candidates for one are often candidates for the other. Both approaches require ongoing monitoring. In the case of surveillance, monitoring is needed to track any possible uptick in tumor activity that would trigger a biopsy/treatment. For focal therapy, it’s essential after treatment to check for recurrence or the emergence of a new tumor.
A key criterion for choosing Active Surveillance is psychological and emotional tolerance for leaving known cancer in place. Many patients who are not comfortable with this idea turn to focal treatment as a way to destroy the known tumor without closing off any future options.
In this exciting time of changing clinical practice for PCa treatment, the Sperling Prostate Center offers the leading program in Focal Laser Ablation. As the most experienced practitioner of FLA, Dr. Dan Sperling and his expert staff offer patients top-shelf excellence in the detection, diagnosis, and focal treatment of prostate cancer. Contact our Center for more information.
[ii] Daskivich TJ, Lai J, Dick AW, Setodji CM, et al. Variation in treatment associated with life expectancy in a population-based cohort of men with early-stage prostate cancer. Cancer. 2014 Dec 1;120(23):3642-50.
[iii] Witherspoon L, Lau JL, Breau RH, Knee C et al. Reducing overtreatment of prostate cancer by radical prostatectomy
[iv] Charnow, Jody. “Surgical Overtreatment of Prostate Cancer may be Decreasing.” Renal & Urology News, May 3, 2018.