Enzalutamide vs AS Slows PCa Progression

FROM THE MEDICAL DIRECTOR

Should Active Surveillance for Cancer Be Rebranded?

An outstanding primary care physician asked me to see an 86-year-old man with elevated PSA. His rationale was that the patient is fit, has an excellent quality of life and “just doesn’t want to die from cancer.” The interaction underscores the trust physicians and patients have in our ability to detect and manage heterogeneous cancers which, depending on many variables and competing risks — known and unknown, quantifiable, and unmeasurable — may or may not be lethal.

A cancer diagnosis changes patients’ lives, a point reflected in the title of the Pulitzer Prize-winning book The Emperor of all Maladies: A Biography of Cancer by Siddhartha Mukherjee, MD. In years past, early detection was the only hope, whereas late-stage disease was nearly universally fatal in short order.

As our understanding of the diverse natural history of screened cancers has grown, active surveillance (AS) of many low-risk solid urologic tumors is now acceptable and guideline based. Finelli et al1 recently reviewed the Canadian experience in over 8500 men with low-risk prostate cancer who initially underwent a period of AS (2008-2014). While there was a near doubling in the use of AS (from 38% to 69%) as a management strategy, the researchers noted that more than half of the men sought active treatment after a median of 48 months follow-up. Importantly, only half of those men chose active treatment due to grade progression.

While retrospective analyses like these create more questions than answers, what remains clear is that once a diagnosis of cancer is made, many patients will choose treatment. This has led to past calls to rebrand nonlethal cancers. One such term, IDLE, or indolent lesions of epithelial origin, proposed almost a decade ago, remains relegated to Pubmed.2

Many justifiably fear cancer. While the idea of AS continues to slowly gain acceptance, most patients are easily moved toward treatment. We must continue to research and educate patients on the differences between a histologic diagnosis of cancer and a biologic one, and decide if we define cancer by its beginning or by its end when creating a treatment plan. We must also work to understand and communicate the tradeoffs with our current interventions and acknowledge the limitations of “shared decision making” when there are significant knowledge differentials between patients and providers.

It’s time to acknowledge the biases patients and physicians have regarding AS for “cancer” and rebrand the concept.

Robert G. Uzzo, MD, MBA, FACS

G. Willing “Wing” Pepper Chair in Cancer Research Chairman, Department of Surgery, Fox Chase Cancer Center, Temple University, Philadelphia

1. Timilshina N, et al. Factors associated with discontinuation of active surveillance among men with lowrisk prostate cancer: A population-based study. J Urol. Published online ahead of print August 20, 2021. 2. Esserman LJ, et al. Addressing overdiagnosis and overtreatment of cancer: a prescription for change. Lancet Oncol. 2014;15:e234-242.

EDITORIAL ADVISORY BOARD

Medical Director, Urology

Robert G. Uzzo, MD, MBA, FACS

G. Willing “Wing” Pepper Chair in Cancer Research Professor and Chairman Department of Surgery Fox Chase Cancer Center Temple University School of Medicine Philadelphia Urologists

Christopher S. Cooper, MD

Director, Pediatric Urology Children’s Hospital of Iowa Iowa City

R. John Honey, MD

Head, Division of Urology, Endourology/Kidney Stone Diseases St. Michael’s Hospital University of Toronto

Stanton Honig, MD

Department of Urology Yale University School of Medicine New Haven, CT

J. Stephen Jones, MD

Chief Executive Officer Inova Health System Falls Church, VA Professor and Horvitz/Miller Distinguished Chair in Urologic Oncology (ret.) Cleveland Clinic Lerner College of Medicine Cleveland

Jaime Landman, MD

Professor of Urology and Radiology Chairman, Department of Urology UC Irvine School of Medicine Orange, CA

James M. McKiernan, MD

John K. Lattimer Professor of Urology Chair, Department of Urology Director, Urologic Oncology Columbia University College of Physicians and Surgeons New York

Kenneth Pace, MD, MSc

Assistant Professor, Division of Urology St. Michael’s Hospital University of Toronto Vancouver, Canada Medical Director, Nephrology

Kamyar Kalantar-Zadeh, MD, PhD, MPH

Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation UC Irvine School of Medicine Orange, CA

Nephrologists

Anthony J. Bleyer, MD, MS

Professor of Internal Medicine/Nephrology Wake Forest University School of Medicine Winston-Salem, NC

David S. Goldfarb, MD

Professor, Department of Medicine Clinical Chief New York University Langone Medical Center Chief of Nephrology NY Harbor VA Medical Center

Csaba P. Kovesdy, MD

Chief of Nephrology Memphis VA Medical Center Fred Hatch Professor of Medicine University of Tennessee Health Science Center Memphis

Edgar V. Lerma, MD

Clinical Associate Professor of Medicine Section of Nephrology Department of Medicine University of Illinois at Chicago College of Medicine Chicago

Allen Nissenson, MD

Emeritus Professor of Medicine The David Geffen School of Medicine at UCLA Chief Medical Officer, DaVita Inc. Denver

Rulan Parekh, MD, MS

Associate Professor of Pediatrics and Medicine University of Toronto

Robert Provenzano, MD

Associate Professor of Medicine Wayne State University School of Medicine Detroit Vice President of Medical Affairs, DaVita Healthcare Denver

Robert S. Rigolosi, MD

Director, Regional Hemodialysis Center Holy Name Hospital Teaneck, NJ

Renal & Urology News Staff

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