A physician and a journalist react to NIH prostate cancer active surveillance conference

Posted by        Gary Schwitzer

Here are two perspectives on last week’s NIH State-of-the-Science Conference: Role of Active Surveillance in the Management of Men With Localized Prostate Cancer.

The first is from one of our HealthNewsReview.org medical editors, Richard M. Hoffman, M.D., M.P.H., Professor of Medicine at the University of New Mexico School of Medicine and Staff Physician at the New Mexico Veterans Affairs Health Care System.  Hoffman spoke at the conference on “Improving the Communication of the Benefits and Harms of Treatment Strategies.” He writes these after-thoughts:

“I just returned from attending an NIH State-of-the-Science conference on active surveillance (AS).  AS is a strategy for monitoring men with low-risk prostate cancers using PSA tests, digital rectal examinations, and prostate biopsies in order to avoid or delay undergoing active treatment with surgery or radiation.  The rationale for AS is that many men with low-risk cancers are unlikely to ever suffer any clinical problems.  Therefore, aggressively treating these men, which can adversely affect urinary, sexual, and bowel function, is unnecessary.  However, identifying patients who are truly low-risk is challenging.  In contrast to the often unwelcome approach of watchful waiting, which provides only palliative treatment for symptomatic cancer progression, active surveillance allows men with low-risk cancers to initially avoid treatment and still be able to subsequently undergo attempted curative therapy if there are signs of cancer progression or they change their mind.

Active surveillance is being evaluated in an ongoing randomized trial in the United Kingdom, but data from observational studies and randomized comparisons of surgery with watchful waiting suggest that AS can be a safe and effective strategy.  The NIH convened a panel to evaluate the evidence.  Their final draft report, issued on December 7, is a thoughtful document that generally supports AS with the caveats that more research is needed to identify optimal patient selection criteria, monitoring strategies, and triggers for active treatment while also measuring the benefits and harms of active surveillance that matter most to patients.

This rigorous scrutiny of an innovative treatment strategy is laudable.  Ironically, I’m not aware of any similarly stringent review being conducted—or expected–when urologists began performing robot-assisted laparoscopic prostatectomy or radiation oncologists began offering CyberKnife and proton-beam radiotherapy—expensive technologies which offered uncertain additional benefits and harms compared to standard treatments.  Meanwhile, a conservative strategy designed to minimize the harms of unnecessary treatment receives a cautious endorsement.

If our society is committed to improving patient-centered health outcomes and controlling health care costs, we cannot afford this double standard. We must address the unbridled dissemination of new technologies.  Such a daunting effort may require regulatory changes for introducing new technologies, reconsidering how care is reimbursed, creating expectations for documenting clinical effectiveness, and providing counter detailing for the public and patients–who all too often are seduced by the marketing hype that innovation and high-technology equals effective, safe, and necessary care.”

The second perspective comes from journalist Laura Newman, who wrote, “Let’s Not Call it ‘Prostate Cancer.’ ” Excerpts:

“The Panel said that terminology matters and that men who have PSA screening results that read 10 ngs or less with a Gleason Score of 6 or less should no longer be told that they have “cancer.” “The word “cancer” sets off an emotional response,” said Barry A. Kogan, MD, part of the Consensus Development Panel, and chair of urology, Albany Medical Center, Albany, NY, during the briefing. According to the Panel’s preliminary report, more than 100,000 men fit within the thresholds above, and are candidates for active monitoring.

If active surveillance gained visibility and credibility, it would be a seachange in practice. The Panel declined to say what term should replace “cancer,” instead leaving it to expert pathologists and urologists  to sort out the science and meaningful language….

Some doctors are simply too entrenched in treatment for a variety of reasons so that active surveillance is anathema. Further, many physicians claim that they have active surveillance protocols, but the exact thresholds beyond which they would advise treatment and whether they are based in science or opinion are not easy for patients to pinpoint. For example, many doctors may be uncomfortable with cutpoints as high as 10 ng PSA and Gleason Score of 6 less for “cancer.”

I asked Ashutosh Tewari, MD, Director of the Robotic Cancer Institute, Cornell University Medical Center, NY, to clarify his position on active surveillance. He has gone on record at urology meetings as supporting active surveillance and has invited leading researchers who back it to speak with residents. He emailed me back: “Active surveillance is the right treatment and we do it here all the time.” Later, he called me to tell me that he has “hundreds of men on active surveillance.”  Tewari is a leading robotic prostatectomy physician internationally. Robotics is an extremely lucrative field. Many people might wonder whether people invested in robotics could be totally objective. One physician who asked not to be named, remarked: “There is too much money to be made to really push it [active surveillance].”

Perhaps one day, volume of procedures will not be so inextricably linked to physician income. Health care reform with incentives for value and good outcomes would be a start.”

The bold emphasis in each person’s comments was mine, pointing out how a physician and a journalist came to the same topic of expensive technologies and questions of evidence and outcomes.