How will the ProtecT study affect your care of PCa patients?

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: How will the ProtecT study affect your care of PCa patients?

“I’ve introduced a lot of people into active surveillance. They have to meet certain criteria. They have to be followed very carefully. Ten to twenty percent of those people will progress unexpectedly and have a less than favorable outcome, but that’s not going to change how I practice.      

If they meet the criteria for active surveillance, I actively try to persuade them to do that. If they don’t feel comfortable, obviously I offer robotic prostatectomy or radiation therapy.

I would say two-thirds of men are willing to try active surveillance, but at least a third are not comfortable; they just want the cancer out. They don’t want to have to come back for a PSA three or four times a year and repeat biopsies every 1 to 2 years. There is a commitment that goes into that. When you look at robotic prostatectomy or brachytherapy, they’re both relatively easy treatments to go through with good results. Particularly younger guys may not want to do active surveillance. There’s some logic to that because eventually in 10, 20 years, they are likely to progress and need treatment later anyway.”

Gregory McCoy, MD

Portland, OR

Next: "You have to understand where the man’s anxiety level is"

Dr. Moore“It won’t have much of an impact on my practice, because I’ve had a pretty strong emphasis on watchful waiting for men with early-stage prostate cancer for several years. Probably 75% of men diagnosed with prostate cancer in my practice are men I just follow with active surveillance.

It’s seldom that I’ve seen those men’s cancers get away from me in terms of developing metastatic disease or incurable disease while on surveillance. I still aggressively treat high-grade disease-4+4 or higher-because those do need treatment. As we all know, prostate cancer has a long natural history to it, so many of my patients with very low-stage disease are good candidates for active surveillance.

You have to understand where the man’s anxiety level is, but when I tell him I don’t want to create a situation where the treatment is worse than the disease, that’s a very convincing argument. Many of them want to hear that and are more comfortable following active surveillance protocols even if more aggressive treatment will be needed in time.

I’ve been doing active surveillance for the past 5 to 7 years, which isn’t really very long. From what I know from research centers, however, many in this population who are on active surveillance (about 30%), at 5 years out, are going to require treatment. At 10 years out, I think 50% will require treatment. But that means that even 10 years out, 50% of men are still showing no significant advancement of their cancer.”

Steven R. Moore, MD

St. Paul, MN

Next: "Over the past few years, I’ve been pushing patients with low-grade prostate cancer into active surveillance"

“I found it reassuring that active surveillance outcomes were shown to be no different compared to radiation and surgery, because we’ve probably been over-treating a large amount of prostate cancer.

Over the past few years, I’ve been pushing patients with low-grade prostate cancer into active surveillance. Because the side effects of treatments can be so impactful on the patient’s quality of life, it’s nice to have the validation of a larger study when we talk to patients-saying we’ve compared surveillance to radiation and prostatectomy, and no matter what you choose, low-grade cancer outcomes are going to be the same.

Patient responses are mixed. Some are not bothered by the word ‘cancer’ at all. When they hear that it’s low grade, they’re comfortable watching it. They really don’t want treatment. Other patients are very scared of that word. Regardless of how low risk it is, they want to treat it. I often find that the wife has an impact. Men go home, having chosen no treatment, then come back with their wives and say they changed their mind.

The problem is the side effects of treatments-erectile dysfunction, incontinence, changes in bowel and bladder habits-have such an impact on quality of life that although numbers may be down, you can still see complications. That’s why a lot of men decide active surveillance may be best until they actually need treatment.

The biggest problem with surveillance is that men don’t really like to have repeat biopsies. But I have one guy who’s been on active surveillance for 3 years with three biopsies. He still doesn’t need treatment, so his potency and urinary habits are still good. That’s 3 years we haven’t impacted his quality of life that significantly.”

Hadley Wyre, MD

Lawrence, KS

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