— FRONTLINE CANCER:
After skin cancer, prostate cancer is the most common malignancy among American men, with 180,000 new cases each year. It’s the second leading cause of cancer death in men (more than 26,000 annually); only lung cancer kills more.
Changing these grim statistics demands steadfast effort. Helping lead the effort is Christopher Kane, M.D., FACS, professor and chair of the Department of Urology at UC San Diego Health and a member of the leadership team at Moores Cancer Center.
As an internationally recognized expert on prostate cancer (he’s on the National Comprehensive Cancer Network’s (NCCN) prostate cancer task force and co-chair of National Cancer Institute Task Force), I recently asked Chris to weigh in on a disease that one in seven men will be diagnosed with in their lifetime, and which will kill approximately one in 39, according to the American Cancer Society. Here’s what he said:
There are two issues here. The first is prevention and prevention of over-treatment and the second is improving care for men with serious prostate cancer. Let’s talk about the first and leave the second for a later column.
Prostate cancer screening and treatment has undergone rapid changes over the past five years. First, the U.S. Preventive Services Task Force gave prostate cancer screening a D grade because of the lack of specificity of screening, meaning many men were having a lot of diagnostic tests done for abnormal prostate-specific antigens (PSAs) who did not have prostate cancer. Second, men with low-aggression prostate cancer appeared to be receiving a lot of surgery and radiation therapy that was potentially unnecessarily.
Many of us in the prostate cancer care arena disagree with abandoning PSA screening because it has been effective at lowering prostate cancer mortality by approximately 50 percent since the early 1990s. It also appears that prostate cancer exists almost as two different conditions. The first is common with aging, occurring in up to half or more of elderly men. The condition does not seem to progress or cause harm. The second is a major public health burden.
So how do we reconcile the varied natural history of prostate cancer and continue screening and detecting cancers at a curable stage for the men at serious risk?
Many of us believe that avoiding over-treatment of very low-risk cancers is an important part of continuing to advocate for screening and detection. Men with the lowest grade or least aggressive prostate cancer — a low PSA and very small cancers — have less than a 1 percent chance of developing advanced prostate cancer within 10 years. Active surveillance, which is a strategy of careful monitoring, is safe for the majority of these patients. Active surveillance includes periodic blood tests and rectal exams with repeat imaging and repeat prostate biopsies every year or two. NCCN guidelines include active surveillance as a preferred strategy for men with very low-risk prostate cancer. The American Society of Clinical Oncology has just issued guidelines with the same recommendation.
At UC San Diego Health, we have been using active surveillance for men with low-risk prostate cancer for more than a decade. We have developed new imaging technologies that help men track their low-risk prostate cancer and help guide repeat biopsies to ensure we’re not missing cancer progression.
One of our urologists, Kelly Parsons, M.D., associate professor of surgery and a surgical oncologist, is leading a national clinical trial of a prostate cancer vaccine called PROSVAC in men who are on active surveillance for low-risk prostate cancer. And we are collaborating with Genesis Group, which includes many private practice urologists in San Diego, on an initiative to boost use of active surveillance.
I tell patients I support the current American Urologic Association guidelines that suggest there is value to continuing prostate cancer screening. I reassure men that if they are diagnosed with very low-aggression cancer, we will embrace active surveillance to avoid over-treatment.
The process of active surveillance can feel incomplete or inadequate to some patients and family members. They worry about following a cancer, rather than fighting it. Interestingly, there is discussion in oncology circles about changing the name of low-risk prostate cancer to improve the acceptance of active surveillance and to ease these worries.
I tell my patients that when we evaluate large studies of men on active surveillance who have been tracked for more than 15 years, the chance of prostate cancer death in those men is under 1 percent. But that said, active surveillance requires active follow-up. Some men will be found to have growing tumors. The goal of AS is to identify these tumors that need prompt treatment so patients receive effective treatment.
The concept of active surveillance is gaining traction, nationally and around the world.
— Scott M. Lippman, M.D., is director of UC San Diego Moores Cancer Center. His column on medical advances in cancer research and care appears in La Jolla Light the fourth Thursday of each month. E-mail: firstname.lastname@example.org