Managing prostate cancer with active surveillance

Vincent Gnanapragasam, at the University of Cambridge, on the other hand believes that immediate treatment may sometimes do more harm than good. His data show that active surveillance, where you keep a watchful eye on a patient and act only when prompted to do so because tests show that the disease is evolving, have the same outcomes for mortality as early interventions, but without the risks of treatment side effects. This protocol has actually now been embraced by Ireland as their standard of care…

Vincent - If you have disease which is of a poor prognosis, almost inevitably you will need treatment, and those men are directed towards curative treatments that could include surgery or radiotherapy. If you have disease on the better end of the spectrum, then here is where the real conundrum comes as to what is the best thing to do. Because prostate cancer, by and large, is not a lethal disease. It is a disease with a long natural history, and actually the old saying that most men will live with prostate cancer and not die from it is absolutely true. So what we do is we give the odds. Now here it's really important to understand the other factors in that person's life. What other illnesses do they have? How old are they?

And we present the data about the value of treatment benefit. Now once a man has that information, he can then make informed choices and decisions about whether or not to have treatment or, very crucially, go into a programme of active surveillance or monitoring, which means that we keep an eye on things with regular blood tests, interval scans, perhaps repeat biopsies. And if in future things change or progress, then we can treat. And that approach has been shown to be as good as treating someone up front, without all the risks and side effects and all the problems.

Chris - That is something you've been pioneering, isn't it? I mean, that's an approach that you've developed where you've said, well, let's compare people who we do an active surgical intervention with people where we keep an eye on things. And what is the outcome of that?
If you compare people who have one or the other, does one group do better?

Vincent - Now, it's not about doing better or not, because actually we know the outcomes are the same. In other words, the chance of survival is pretty much the same. Very small differences. It's about whether or not we are doing any good with a treatment up front, or whether surveillance is the best thing to do—and then think about treatment if necessary.

Chris - So you could actually be doing harm then. If you were to go in and do surgery on those people who would do as well as if you left them alone, then really they could come out worse off, couldn't they? Because of all the risks of surgery for no clinical benefit.

Vincent - Absolutely.

Chris - I suppose there could be a psychological one. Having said that, if I know I've had the area that was detected as abnormal removed, that makes me feel better mentally.

Vincent - Well, first, let me address the issue of the effects of treatment. So any treatment, no matter what it is—whether it's radical whole gland or other types of treatment—has the risk of side effects. And we know very well that a lot of men who get treatment for early disease actually will gain no survival benefit but will have all the after-effects and problems of the treatment. And really, my mantra has always been: treat something if it needs to be treated, but don't treat it if you don't need to treat it. We have very robust surveillance mechanisms which work extremely well, which we have shown and published. And that is what happens to men who don't need immediate treatment.

Now, regarding this aspect of psychology, I think that if a man continues to be anxious about a prostate cancer diagnosis after they've been through our clinic and process, then it's a failure of counselling. What we should not be doing is trying to give treatments which, if you like, palliate psychological anxiety—both on the part of the patient and also the clinician, urologist, or oncologist. That is bad medicine. It is our duty and job to actually give the information that explains to an individual why something needs to be done. And one of the biggest things that I find in my practice is we get a lot of men who come to us and a lot of men who will say, "Well, what would you recommend?" because they want someone to tell them, and they find it very strange we’re not doing that. But of course, the whole reason why we don’t is because we know very well that we are likely to do more harm than good, and that probably this prostate cancer may never affect them.

Chris - Is there not a problem though, Vincent, that as you go further on down this path, given the ageing population and given a watch-and-wait strategy that you're advocating for, you're going to accrue a massive list of people that you're keeping an eye on?

Vincent - Can we resource that? Active surveillance has been very badly resourced. No one is interested in it because, well, it's not very exciting for a lot of doctors. But it is crucial for patients. So we have developed a very structured surveillance programme which actually empowers the patient to self-monitor. So we give them the tools to do this. Each patient on our surveillance programme is given a particular regime of follow-up, what to expect.
We also tell them how to do their PSAs, what to look for. We find that actually we've managed to increase our active surveillance population without actually having to increase our clinic footstep.

Chris - I read that this has now been embraced by Ireland. This is their de facto way of doing prostate management, but not the UK.

Vincent - Well, not so far, Chris.

Chris - Why not?

Vincent - Well, I think you'd have to ask NICE about that. We are planning to approach them to present the evidence and the data. And one of the problems with active surveillance is that it's been rife with opinion and it's been rife with variances in practice. I often refer to active surveillance in the UK as the Wild West of prostate cancer management, because whereas you have high-quality standards for surgery or radiotherapy—you can measure what's happening and you track patients—in surveillance, no one does that.