Prostate Cancer Active Surveillance: Who, When & How

[Dr. Jeff Cadeddu]
I don't do that in clinical practice. In my practice, at least it takes a little bit too much time. I also find that giving or providing data regarding nomograms to patients, the average patient, at least in Texas comes back to what you said, which is, "Doc, what would you do?" Right? So I don't find doing that. I do risk stratify everybody per AUA and NCCN guidelines, and then provide them with that information. And that the favorable and unfavorable intermediate risk, if they have a 10-year life expectancy, they would benefit from treatment at least in preventing metastasis. And if they have a long enough life expectancy would probably benefit from, in terms of dying of prostate cancer.
The high risk patient, I think, as long as they have a life expectancy of five to eight years probably would benefit from treatment. And I just kind of ballpark it for the patients. I think patients like that going into... This is the rare patient who can understand the nuances of some of those nomograms.

[Dr. Aditya Bagrodia]
Yeah. I wholeheartedly agree. I think you have to read the room a little bit and see what's going to be a digestible format for the patient. Life expectancy prediction is tricky business. We've all seen patients that are 50 that look like they're 80 and vice versa. You mentioned five years as a landmark that pops up in the AUA guidelines, 10 years. How do you assess functional status life expectancy?

[Dr. Jeff Cadeddu]
I don't assess it. Again, in the real world, I think community urologists would appreciate the fact that we don't have time to sit around and input patient data into some sort of calculator. You also realize that no patient likes to be told that they're 65 years old. There's no chance in hell they're going to live to 75. So it's nuanced. You talk to the patient and then when you do talk to the cardiologist, which is most of their comorbidities, no cardiologists will stick their head out and say, "Oh, yeah. This patient definitely will be dead in eight years."
Everything's pretty nuanced. Like you said, you have to feel the room, get a gist for the patient's health. If you've got a history and the patient is 70 years old and has diabetes and hypertension and coronary artery disease, I think you have to have a discussion where, okay, well, you might really not get the long term benefit of surgery.
I think that the greatest benefit of surgery is a really long-term. That's 15-year disease free survival. So those patients, it's a pretty easy conversation. Also, it's hard to find it's a 55-year-old who similarly doesn't think they're going to live to 65. So I don't calculate anything, but you can have a co-morbidity discussion with the patient and weigh the benefits of radiation versus surgery.
And in the occasional patient, even active surveillance. But all the nomograms in the world, I think most people in a busy clinical practice will agree that there's still the art of medicine, the nuances of counseling patients and the gestalt of how they're doing. I think patients are honest with themselves and then we'll come to the realization of what may benefit them best.

[Dr. Aditya Bagrodia]
I wholeheartedly agree. I think it goes into, we're trying to convey a message. If I've got a patient that's 77 with a little bit of grade group two prostate cancer, and they want something done, that's the guy that I pull up the life expectancy calculator, put in their history of have you had a TIA, a stroke or is your blood pressure okay? Here's your cancer characteristics. And then this little box pops up. There's a hundred people and it says three men will be dead of prostate cancer. 80 are going to be dead of something else, and seven are going to be alive.
Then I have some ammo to go in and say, "Listen, my bar to help you is 3% and my bar to hurt you is fairly tremendous as soon as I walked through what surgery radiation looks like.

[Dr. Jeff Cadeddu]
This is as much medically complicated and as politically complicated in terms of how to deal with focal therapy or ablation of the prostate. My feeling is that in the low risk patient who qualifies for active surveillance, I don't see any reason that that patient should to go any kind of treatment, whole bland, focal ablation, what have you. We have 15-year active surveillance protocols results for these patients where they didn't have any of these treatments and they're all alive and they're all fine.
So I don't know why you'd treat something that's not a threat. We don't treat other conditions that don't progress. I think if there's progression, then they should undergo the appropriate treatment for that progression. And I don't think they need to undergo focal therapy for something that's low risk.

[Dr. Aditya Bagrodia]
And what are those triggers for treatment in your practice?

[Dr. Jeff Cadeddu]
So rising PSA, right? So certainly we know that as soon as their PSA goes over 10, it's no longer low risk. So if the PSA is trending towards that, I think that's a concern, the PSA philosophy, right? We can have upgrading on subsequent biopsy, MRI biopsy. So my triggers would be either upgrading or upstaging either by MRI or PSA progression.

[Dr. Aditya Bagrodia]
Right. We're fortunate to have a really tremendous team offering MRI inboard biopsies, MRI ultrasound fusion biopsies. And let's say they've been five or six cores coming out of a single lesion that are all grade group six, patient is little nervous. How do you handle that, that situation?

[Dr. Jeff Cadeddu]
If you have a lesion in your biopsy 10 times, you'll have 10 of 10 cores, if it's all Gleason 6, right? The number of cores in targeted biopsies are done to increase the yield, but the number of cores themselves should not drive the decision-making. Right? So I would say if they have a five millimeter, PIRADS 3, PIRADS 4 lesion on MRI, and you have three out of three cores that are Gleason 6, it's probably reliable.
If it's a 17 millimeter lesion on MRI and you have three cores and three out of three are Gleason 6 may not be as reliable, right? So this is no different than kidney tumor biopsy now. So the number of cores, I think, is also relative to the size of the lesion. And I think that would influence how you counsel the patient.