When "Do No Harm" Means "Do Nothing": Evolving Protocols

Vincent Laudone

Urologic surgeon Vincent Laudone

Our conversation about active surveillance of prostate cancer continues. In previous posts James Eastham and I wrote about the benefits this management strategy offers some patients and how we manage risks. Recently a reader asked what the protocol is for selecting and following patients on active surveillance.

In fact, our protocol is constantly evolving. One reason for this is that we continually gain new information by analyzing patients who have been on active surveillance to date. We now have experience managing more than 1,000 patients with prostate cancer on active surveillance for up to ten years.

Choosing the Right Approach for Each Patient

From this experience, we have learned that the most important factor in achieving a successful outcome for patients on active surveillance is to be certain from the very beginning that their cancer is appropriate for this approach. For this reason we now routinely do a prostate MRI at the time of initial diagnosis, and, if indicated, a second or “confirmatory” biopsy.

In addition, the recent availability of genomic testing now gives us an enhanced ability to better assess the aggressiveness of an individual cancer based on DNA analysis of the biopsy samples. Taken together, all of this information is used to determine which patients are good candidates for active surveillance and which patients should receive immediate treatment.

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Following Patients

When it comes to following patients on active surveillance, advances in MRI technology —including stronger magnets and better software — continue to reduce the need for repeat prostate biopsies over time. The information gained over the past several years along with the technological improvements now allow us to individualize the follow-up regimen for each patient, tailoring the schedule to fit the aggressiveness of the cancer and the patient’s characteristics, such as age and health status. Most men on active surveillance are seen every six months for a routine exam and PSA check, with follow-up MRI and biopsies as circumstances warrant.

Finally, our experience gained thus far has given us reason to consider active surveillance not only for very low-volume, low-grade disease but also for a broader group of patients, including men with higher-volume Gleason grade 6 disease, or even low-volume Gleason grade 7 disease.

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Vincent P. Laudone is a urologic surgeon specializing in robotic surgery.


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Is an MRI done to determine if cancer is present before doing a biopsy?

Dear Anthony, we sent your inquiry to MSK surgeon Dr. Vincent Laudone and he responded:

“This is a good question. The use of prostate MRI has being increasing in
recent years as the technology has improved and we have gained more
experience interpreting the results of the MRI images. Memorial Sloan Kettering has been a leader in the use of prostate MRI for more than a decade. Most recently, technology has been developed that allows for the MRI images to be incorporated into the ultrasound procedure used to obtain a prostate
biopsy (known as “MRI fusion biopsy”). This enables us to precisely target any abnormalities seen on the MRI during the biopsy procedure. Several hundred of these MRI fusion biopsies have been performed at MSKCC with excellent results. Given the availability of this enhanced technology, we are now doing prostate MRIs in most patients prior to prostate biopsy. In must be realized, however, that doing an MRI adds significantly to the cost of diagnosis, and that the MRI alone cannot be used without the biopsy to make a diagnosis. Lastly, not all patients can have an MRI if they are claustrophobic, have a pace maker, or certain other internal metal items.”

If you would like to make an appointment with a specialist at Memorial Sloan Kettering, please contact our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

I'm 54 years old ,diagnosed with gleasons 6(3+3), Fish negative, 25% of 1/16 cores ,doing great with Alfuzosin , Is it right I want to do irreversible electroporation instead just only active surveillance ?

At age 53 years I have been diagnosed with prostate cancer in Dec.2015. A biopsy was done on 12/7/15. So 8 of 12 cores came positive .My Gleason score is 3+3=6, PSA 7.5 on 12/7/15.The first MRI is done on 2/14/2016 and its PIRAD 3 but my PSA came down from 7.5 to 3.82 within 8 weeks. I believe Its so because I started taking some special diet and some homeopathic remedies after my diagnosis around Dec.15. Cancer is confined to Prostate capsule. If my PSA had not come down in these 8 weeks, I would have opted for a radical prostatectomy after my first MRI on 2/14/16. However I have a question to ask to our medical intelligentsia, scholars and researchers.Does it have a scientific relevance that PSA came down from 7.5 to 3.82 and if we do another MRI in next 2 months say 4/30/2016 and compare with the first MRI done on 2/14/2016, there are chances that cancer is in the regression (because the PSA is already coming down). If the comparison of two MRIs approves the regression of cancer then I continue with same alternate therapies otherwise I will go for a prostatectomy. I will appreciate your comments.

Ashraf Azim

Ashraf, thank you for reaching out. We suggest you speak with your doctor about your best options, as every individual case is different and can be affected by a variety of factors.

If you would like to make an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at
800-525-2225 or go https://www.mskcc.org/experience/become-patient/appointment
Thanks for your comment.

You mention active surveillance for those patients "even with low 7 gleason scores"...what about above 7...like 9? What would be the recommended protocol for that advanced stage?

Kathryn, thank you for reaching out. We consulted with Dr. Laudone on your question, and he responds:

Patients with high grade prostate cancer such as those men with Gleason Grade 9 disease are not candidates for active surveillance. In these men, we consider all treatment options and most often think in terms of combining treatments in what is known as “multimodality” therapy. This includes radiation, surgery, hormonal therapy, immunotherapy, and chemotherapy in various combinations and variable sequence. The concept is to better manage the local disease in and around the prostate as well as address possible or actual cancer that has spread from the prostate to other sites such as the lymph nodes or bones. The exact treatment regimen thus becomes much more individualized and depends on the extent of the disease as well as the age and health of the individual.