We have occasionally posted blogs about the grassroots influence that prostate cancer (PCa) patients can have over trends in PCa treatment. For example, patient desire and demand for less invasive treatments that can diminish their quality of life played an enormous part in the evolution of focal therapies, such as our own Focal Laser Ablation.

Now it’s the doctors’ turn. At the Sperling Prostate Center, we want to acknowledge the physicians, especially urologists, who protested a simple one-word change in an important treatment guideline. Specifically, in September 2021 the National Comprehensive Cancer Network (NCCN) came under physician fire for reducing the status of Active Surveillance (AS) as a preferred treatment option for low-risk PCa. By eliminating that single word, they put prostatectomy, radiation, and AS all on the same choice level for low-risk disease. However, they kept the preferred status for very low-risk PCa, implying that it should be a primary option before surgery and radiation. In revising the guideline for low-risk disease, the new NCCN wording made it sound like “… it is no less appropriate to do surgery or radiation than it is to do active surveillance for low-risk disease,” according to respected urologists Dr. Matthey Cooperberg (UCSF).^[i]

When Dr. Cooperberg’s protest sounded the call to arms, many other authoritative urologists who champion AS also spoke up, such as Dr. Stacy Loeb (NYU) and Dr. Brian Helfand (Northshore University Health System). In fact, a groundswell of urologic opinion hit the NCCN like an unexpected tidal wave. The patient voice also chimed in, as PCa advocacy groups likewise issued statements from their spokespersons—but it was the urologic community that led the charge.

NCCN reverses its position

The upshot was a November 30, 2021 reversal of the wording, an action that Dr. Cooperberg called “a change very much in the right direction.”^[ii] Perhaps his enthusiasm was somewhat tempered by the fact that the new NCCN guideline for low-risk PCa reads “Active Surveillance (preferred for most patients).” For most patients? While that may seem overly cautious — why not all low-risk patients? — in fact it’s meant to encourage more doctor-patient discussion of options, and shared decision making.

One factor underlying the preferred treatment issue is the distinction between very low vs. low risk levels. While there are distinctions such as percent of tumor in biopsy needles or tumor size, both of them are considered Grade Group 1. Pro-AS urologists tend to see both risk levels as candidates for AS.

Dr. Cooperberg points to recent history:

As a specialty, we need to recall that overtreatment of low-risk disease was a major cause of the ‘D’ recommendation from the [U.S. Preventive Services Task Force] against all screening, and improved rates of surveillance were an explicit driver of the revision in favor of shared decision-making. Gleason grade group 1 tumors, regardless of volume, are very rarely lethal, with or without treatment.^[iii]

What’s important is that NCCN include both levels in their guidance on candidates for AS, and we agree with this position. It has taken over two decades of advances in a) imaging technology, b) targeted biopsy, c) tumor genomics, and d) biological understanding of the natural history of PCa, to get to our current acceptance of AS for appropriate PCa cases.

At the Sperling Prostate Center, we provide state-of-the-art multiparametric MRI and in-bore MRI targeted biopsy to identify and support candidates for AS. We recognize the tremendous value it has for the right patients. At the same time, many of our patients who clinically qualify for AS have reservations about leaving PCa untreated in their bodies, while at the same time they don’t like the idea of urinary and sexual side effect risks of whole gland treatment. For them, Focal Laser Ablation (FLA) is an ideal middle ground. It offers the advantage of cancer control while preserving quality of life. Once treatment is complete, each patient embarks on a surveillance protocol similar to that of AS in order to monitor the untreated prostate tissue that continues its gland function.

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] Wolinsky, Howard. “One-Word Change in Prostate Cancer Guideline has Some Urologists Up In Arms.” MedPage Today, Oct. 4, 2021. https://www.medpagetoday.com/special-reports/apatientsjourney/94840
[ii] Wolinsky, Howard. “NCCN Reverses on Guideline Change for Surveillance in Prostate Cancer.” MedPage Today, Dec. 1, 2021. https://www.medpagetoday.com/urology/prostatecancer/95949
[iii] Ibid.