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Watchful Waiting and Active surveillance for low risk prostate carcinoma Maurizio Brausi
Un programma di sorveglianza attiva e’ alla portata di tutti i centri ?
EAU guidelines 2012: Indications
Active Surveillance: Follow-up
Patients who are in AS protocols should be controlled periodically.
* PSA every 6 months
* Prostate Biopsy at 1-2 years
* MRI could be used instead prostate biopsy ?
A Multisciplinary Approach To Prostate Cancer
WHY A MULTIDISCIPLINARY MANAGEMENT OF CANCER ?
AIMS OF A MULTIDISCIPLINARY TEAM FOR CANCER
(Prostate Cancer Unit)
PROSTATE CANCER UNIT Ausl Modena
D: Un Programma di AS è alla portata di tutti i Centri Ospedalieri ?
Risposta: E’ alla portata della maggior parte dei centri Ospedalieri che hanno la possibilità di controllare i pazienti periodicamente e di eseguire biopsie prostatiche in tempi adeguati. L’approccio multidisciplinare dovrebbe essere una priorità
In cosa un programma di AS differisce da un programma di WW ?
EAU guidelines 2012: definizioni
EAU guidelines 2012: WW in PC T1-2/N0/M0
EAU guidelines 2014: AS
EAU Guidelines 2014: AS
D: In cosa Differisce un programma di AS da un programma di WW ?
Risposta Un programma di AS prevede l’attento e periodico monitoraggio del paziente (ogni 6 mesi con PSA) e controllo della prostata con biopsia ogni 1-2 anni.
Un programma di WW non prevede controlli periodici e tratta il paziente alla presenza di eventuali sintomi.
Risks of Active Surveillance Protocols
Active Surveillance
It is not a strategy for everyone with low risk PC but should be one option or probably the first option.
It is not a passive approach
The primary goal is not to decrease overtreatment but to maximize the quality of life on an individual basis
Active Surveillance
One should not treat PC as early as possible but as late as possible while still curable with low morbidity
Overtreatment is not only associated to negative impact on Quality of Life but is also very costly
Side-effects from treatment
Permanent side-effects from treatment are common and results in lowered quality of life!!
Side-effects are significantly lower if treated by the most skilful surgeons in high volume centers, but how is it on an average?
Patient Selection For AS
Variable, according to different International protocols:
1-2 core of Pca Gleason score 3+3 < 15% in the core at standard biopsy
Different Methods of diagnosis: If we use standard (12 cores Biopsy) we miss about 30-35% of significant cancer (Gleason score 7). This was studied by a group who performed Template biopsy in patients on AS selected with standard biopsy
Selecting Patients For AS
Multiparametric MRI (3 Tesla) with targeted biopsy will be the future (US Fusion)
The standard in 2013 for diagnosis and patient selection AS is Template biopsy
5 deaths in PC but only one was low risk
60 % of all screen-detected cancers were of low risk
Failure rate measured as tumor recurrence after active treatment (PSA relapse or hormonal treatment)
What is the problem with AS
Close and life long FU contribute to stigmatise the patient
Knowing having PC may cause psychological trauma which in certain individuals may burden the quality of life more than side effects from treatment
We have no validated trigger points for switching to active treatment
Treating men after progression may cause more side-effects than treating men early
Conclusions
Low risk PC is low risk, but be careful some are falsely staged, early re-evaluation!!
The overwhelming majority of men with low risk PC will never develop symptoms and will die from other causes
AS with delayed active treatment in those who need seem to be as effective as treating all actively from start
Existing active treatments that are evidence based are associated with side-effects that will considerably affect quality of life in many patients
Surveillance will maximise quality of life and reduce costs
Future Goals
Find strategies to avoid diagnosing insignificant low risk PC
Better screening tools for detecting biologically significant cancers
Biopsy men more selectively and change from systematic to imaging guided biopsies
What is the risk with low risk PC?
Rider et al Eur Urol 2012
Popiolek et al Eur Urol 2012
Klotz et al JCO 2010
Godtman et al Eur Urol 2012
To undertreat patients who will progress and develop metastatic disease
Pro Surveillance
Jonas HugossonDept of Urology, Sahlgrenska Academy,
Göteborgs UniversitetSweden