Active Surveillance vs. Watchful Waiting in Prostate Cancer Management "Presentation" - Caroline Moore
July 24, 2024
At the CAncer or Not Cancer: Evaluating and Reconsidering GG1 prostate cancer (CANCER-GG1?) Symposium, Caroline Moore discusses the differences between active surveillance and watchful waiting in prostate cancer management. Dr. Moore highlights that MRI-led pathways have reduced the diagnosis of low-risk prostate cancers in England, similar to Australia's experience. She concludes by questioning whether men with Gleason 3+3 should be diagnosed or placed on surveillance at all.
Biographies:
Caroline Moore, MD, FRCS, Professor of Urology, University College of London, London, England, UK
Biographies:
Caroline Moore, MD, FRCS, Professor of Urology, University College of London, London, England, UK
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Read the Full Video Transcript
Caroline Moore: What's the difference between surveillance and watchful waiting? Well, there's a difference in intent. Surveillance is supposed to be looking for the opportunity to offer curative treatment if either the cancer risk or the personal choice changes, whereas watchful waiting is treating symptoms either of local or metastatic disease.
There's a difference in the process. So with us, as in Australia, PSA and MRI biopsy as needed for surveillance, but watchful waiting with perhaps a bone scan if the PSA gets very high. And in terms of treatment, you're looking at either local radical or focal treatment versus hormone treatment or TURP.
So which patients are safe? Everybody in their 70s and over, those with comorbidities, and I'll put it to you that we could consider those two categories, but also those with non-MR visible disease. Similar to Australia, this is the latest England data where we've got an MR-led pathway. We're diagnosing fewer of these men. So 20% of men have Gleason grade one, 6% have low-risk disease.
How does that work out in our UCLH surveillance cohort? So we've got over a thousand men in our MR-led surveillance cohort, and you can see the orange numbers increasing over the years and outnumbering those with Gleason three plus three, so more three plus four than three plus three joining our cohort.
So how many of those three plus threes are non-visible, and how many could we perhaps not look at? So probably at least 40% of the three plus threes are non-visible. And what happens to men with non-visible three plus three? Is it any different from visible three plus three or Gleason three plus four? And it is less likely to progress to need treatment. So in our cohort, only one in four men with non-visible three plus three by 10 years have moved at all, and some of those men have moved into watchful waiting. So it really is much lower numbers moving on to treatment.
So the final question, the caveats here, what are the caveats? Well, you need high-quality MR. But really the final question that I put to you is should we simply not diagnose and certainly not put on surveillance those men with Gleason three plus one? Thank you.
Caroline Moore: What's the difference between surveillance and watchful waiting? Well, there's a difference in intent. Surveillance is supposed to be looking for the opportunity to offer curative treatment if either the cancer risk or the personal choice changes, whereas watchful waiting is treating symptoms either of local or metastatic disease.
There's a difference in the process. So with us, as in Australia, PSA and MRI biopsy as needed for surveillance, but watchful waiting with perhaps a bone scan if the PSA gets very high. And in terms of treatment, you're looking at either local radical or focal treatment versus hormone treatment or TURP.
So which patients are safe? Everybody in their 70s and over, those with comorbidities, and I'll put it to you that we could consider those two categories, but also those with non-MR visible disease. Similar to Australia, this is the latest England data where we've got an MR-led pathway. We're diagnosing fewer of these men. So 20% of men have Gleason grade one, 6% have low-risk disease.
How does that work out in our UCLH surveillance cohort? So we've got over a thousand men in our MR-led surveillance cohort, and you can see the orange numbers increasing over the years and outnumbering those with Gleason three plus three, so more three plus four than three plus three joining our cohort.
So how many of those three plus threes are non-visible, and how many could we perhaps not look at? So probably at least 40% of the three plus threes are non-visible. And what happens to men with non-visible three plus three? Is it any different from visible three plus three or Gleason three plus four? And it is less likely to progress to need treatment. So in our cohort, only one in four men with non-visible three plus three by 10 years have moved at all, and some of those men have moved into watchful waiting. So it really is much lower numbers moving on to treatment.
So the final question, the caveats here, what are the caveats? Well, you need high-quality MR. But really the final question that I put to you is should we simply not diagnose and certainly not put on surveillance those men with Gleason three plus one? Thank you.