Monitoring, Not Treatment, May be Better for Very Low-Risk Prostate Cancer Patients

In a study published online on Oct. 20th in the Journal of the American Medical Association (JAMA) Oncology, more than 90 percent of men in Sweden who have very low-risk prostate cancer choose close monitoring rather than immediate treatment — and more American men should use that option, researchers say.

In a study of nearly 33,000 Swedish men with very low-risk (stage T1) prostate cancer diagnosed between 2009 and 2014, the number choosing what is called active surveillance increased from 57 percent to 91 percent during that time frame.

“For men who are diagnosed with low-risk prostate cancer, it is important to know that active surveillance is an accepted way to manage the cancer,” said lead researcher Dr. Stacy Loeb, an assistant professor in the departments of urology and population health at NYU Langone’s Perlmutter Cancer Center in New York City.

“There is no rush to get treatment — low-risk prostate cancer can be safely monitored,” she added. “Some men will eventually need treatment, but others will be able to preserve their quality of life for many years.”

In the United States, the majority of men with low-risk prostate cancer get treatment upfront, which can have side effects, such as urinary and erectile problems, Loeb said.

Active surveillance isn’t wait-and-see, she explained. It involves regular blood tests and regular biopsies to gauge the growth of the tumor. When the tumor grows to a point where treatment is needed, then it’s time for curative surgery or radiation.

A recent British trial showed that 10 years after diagnosis, the risk of dying from prostate cancer was the same whether men initially had surgery or radiation or opted for monitoring, Loeb added.

“We found that most men in Sweden with low-risk cancers are now opting for surveillance rather than upfront treatment,” Loeb said. “Hopefully, this study can increase awareness among patients in the U.S. and other countries that deferring treatment is an accepted option for low-risk prostate cancer.”

There is a lot of controversy about prostate cancer screening, Loeb noted. “Prostate cancer has no symptoms until it is advanced, so screening is actually very important to find life-threatening cancers in time for cure,” she said.

Patients with high-risk cancer do need treatment right away, and that treatment can be lifesaving, Loeb said. “However, many other men are diagnosed with low-risk cancers that have a very good prognosis without any treatment, and deferring upfront treatment can allow them to preserve their quality of life longer,” she said.

About 181,000 American men will be diagnosed with prostate cancer in 2016, and most of those will be in the earliest stages, according to the U.S. National Cancer Institute (NCI). Approximately 26,000 men will die from prostate cancer in 2016, the NCI estimates. The five-year survival rate for prostate cancer is nearly 99 percent, the NCI says.

“This [study] is more evidence of active surveillance becoming a standard of care,” said Dr. Matthew Cooperberg, an associate professor of urology, epidemiology and biostatistics at the University of California, San Francisco and author of an accompanying journal editorial.

Sweden has been far ahead of the United States in terms of active surveillance, but it is becoming more accepted here, Cooperberg said. About 40 percent to 50 percent of men with low-risk prostate cancer are choosing surveillance, “so we still have some catching up to do,” he said.

Adoption of active surveillance has been slow in the United States for several reasons, Cooperberg added. Among these are the financial and legal incentives to treat patients.

“In addition, culturally Americans have been uncomfortable with the idea of not treating cancer, because of the psychology that comes with the ‘C’ word,” he said. “But things are changing; it’s not such a foreign concept.”

Cooperberg said the future of active surveillance is refining it based on an individual’s cancer, so that tests and biopsies aren’t done on an arbitrary schedule, but on a schedule based on the characteristics of the patient’s tumor.

“Prostate cancer decision-making — from PSA testing on through treatment — really needs to be personalized,” he said.

As always, if this information pertains to your specific diagnosis, it should be discussed with your personal health care provider before taking any action. This report appeared in the October 20th issue of MedlinePlus, published online  by the National Institutes of Health U.S. National Library of Medicine. This information also was posted on-line by Prostate Cancer News Today on October 31st (see link).

Radiation Therapy Improves Survival Over Hormone Therapy (ADT) Alone in Metastatic Prostate Cancer

A large database analysis showed that the addition of external beam radiotherapy (RT) to androgen deprivation therapy (ADT) significantly improves overall survival (OS) in men with metastatic prostate cancer.

“As advances in systemic therapy for metastatic prostate cancer have improved OS and the control of metastatic disease, a greater interest has emerged in therapies to promote local control of the primary prostatic tumor,” wrote study authors led by Chad G. Rusthoven, MD, of the University of Colorado School of Medicine in Aurora. There is relatively limited data so far, though, on the use of external beam RT in these patients.

The study analyzed outcomes from 6,382 men diagnosed between 2004 and 2012 included in the National Cancer Data Base (NCDB), all of whom received ADT. Of these men, 538 (8.4%) also received prostate RT. The results of the analysis were published in the Journal of Clinical Oncology and linked herein.

Those who received RT were younger, had better comorbidity scores, lower prostate-specific antigen levels, and higher T stage, and were more likely to have n0 disease, to be treated at a community facility, and to have private insurance.

After a median follow-up of 5.1 years, the addition of RT was associated with a longer median OS of 53 months, compared with 29 months without RT. The 3-year OS rates were 62% with RT and 43% without RT; at 5 years, these rates were 49% and 25%, respectively, and at 8 years, the rates were 33% and 13% A subgroup analysis showed that the biggest benefit of RT was gained in patients with Gleason scores of 8 or below, and for T1–3 tumors compared with T4 tumors. Higher RT dose was also associated with better OS compared with lower doses.

The analysis has limitations inherent to retrospective cohort studies, including the possibility of selection biases and imbalances. The authors noted that performance status and extent of metastatic disease burden could not be controlled for, and the sites of metastatic spread were unavailable.

Still, they concluded, “In this large contemporary analysis, men receiving prostate RT plus ADT lived substantially longer than men treated with ADT alone. Randomized trials to evaluate the impact of local therapy for men with metastatic prostate cancer appear warranted and several trials are ongoing.”

MRI-Ultrasound Fusion Prostate Biopsy from Johns Hopkins

An excellent 3-minute video from Dr. H. Ballentine Carter, Professor of Urology and Oncology at Johns Hopkins, describes the use of MRI to view the prostate one day prior to performing a standard ultrasound-guided biopsy. The video speaks for itself and can be viewed at the following link.

This technique is also being used at the University of Texas Southwestern. See the following link for a complete description of how it is done and their positive results as compared with standard biopsy techniques.

Using Ginseng for Cancer-Related Fatigue

The following is a summary of an article written by Mark Moyad M.D., Jenkins/Pokempner Director of Complementary & Alternative Medicine at the University of Michigan Medical Center. It was published in the August 2016 issue of Prostate Insights from the Prostate Cancer Research Institute (PCRI). Cancer-related fatigue (CRF) can occur in as many as 60-90% of patients. It is the primary side effect of the approved prostate cancer drug Xtandi® and most other treatments such as Zytiga®, hormone therapy and of course, chemotherapy. In 2014, researchers at Mayo Clinic published the following in the Journal of Clinical Oncology  (Ruddy et al, 2014;32:1865-1867). “For patients who want to try a pharmacologic product and physicians who are early adapters of new promising agents, the pure ground root American (or Panax) ginseng product as used in the above studies may be an option to consider.” Recent studies of the use of ginseng in breast, colon and prostate cancer involved 364 participants in 40 medical centers. After two months of receiving 2000 mg of Wisconsin ginseng (a high quality American ginseng), the study revealed a significant difference as ginseng was twice as effective as placebo in reducing fatigue. In the Phase 3 trial, Mayo researchers also found similar results administering 1000 mg (1 gram) per day in a trial of 290 cancer patients. The ground root ginseng was obtained from the Ginseng Board of Wisconsin. (See or In a study at M.D. Anderson Cancer Center, ginseng was found to also improve sleep, appetite and pain issues. Ginseng also appeared to reduce the inflammatory process associated with chronic fatigue. It may reduce cortisol thus reducing overall stress and improving energy. Whether or not the primary anti-fatigue effects are being derived from the standardized ginsengoside and/or polysaccharides content or another active compound in the supplement is a matter of research and debate. Ginseng produced no real side effects, had no real current strong drug interactions, and did not seem to interfere with major drug metabolism. Ginseng from water extraction or from pure ground root has been associated with the best results and safety. Ginseng extraction methods due to alcohol or methanol-based procedures could be less effective and some researchers believe toxic with long-term use. Ginseng can be ingested with or without food but with a meal gastrointestinal side effects like acid reflux could be reduced. Purchasing ginseng from the Ginseng Board of Wisconsin or from the herb-co-op (see above) eliminated potential quality control and contaminant issues that may arise when purchasing from a local health food store.