Breast cancer: How frequently ought men who are under active surveillance to be evaluated?

Breast cancer: How frequently ought men who are under active surveillance to be evaluated?

Even if initial biopsies indicated that the disease would grow slowly (or at all), doctors used to automatically recommend treating all men with prostate cancer. However, the treatment pendulum has swung the other way over the past few decades.

Active surveillance for low- to intermediate-risk cancers that may never kill a man is now likely to be recommended by doctors. Regular PSA tests, follow-up biopsies, and, more recently, tumor magnetic resonance imaging are all components of active surveillance. Only when the disease is showing signs of progressing does treatment begin.

Men on active surveillance have an average long-term risk of metastasis and death from low-grade prostate cancer of just 0.1%, according to Johns Hopkins University research. However, doctors who treat such men also have to deal with a persistent query: Which of their patients might have cancer that is more advanced and needs to be monitored more closely? The Johns Hopkins team released new findings in January that provide useful insights.

The approach taken by the researchers In this instance, the focus of the research was on the prognostic value of so-called perineural invasion, or PNI, on samples of tumor biopsy. PNI simply indicates that cancer cells are entering the prostate’s perineural space, which is the space between prostate nerves and the tissues that surround them. According to Dr. Christian Pavlovich, a urologic oncologist at Johns Hopkins who led the research, a finding of PNI raises red flags because the perineural space “provides a conduit by which tumor cells can potentially escape the prostate and grow elsewhere in the body.”

The team led by Dr. Pavlovich wanted to know if PNI found on initial or subsequent biopsies would be linked to a higher risk of cancer progression. As a result, they looked at long-term follow-up data from 1,969 men who had signed up for a Johns Hopkins active surveillance research protocol between 1995 and 2021. All of the men had at least one follow-up biopsy since their initial diagnosis of Grade Group 1 prostate cancer, which is the form of the disease with the lowest risk.

What were the outcomes?
Among the 198 men who had PNI, 87 of them eventually developed Grade Group 2 prostate cancer, which is a more advanced form of the disease with a moderate risk of further spread. In total, 44% of these men progressed to this stage. On the other hand, only 26% of the remaining 1,771 men (or 461 men) who did not have PNI had advanced to Grade Group 2.

Pavlovich emphasizes that PNI “does not make patients ineligible for active surveillance” in spite of the new findings. Importantly, the research demonstrated that PNI was not associated with high-risk characteristics, such as patients who had surgery and had cancer in their lymph nodes or elevated PSA levels after surgery, which indicate that cancer is still present in the body.

According to Pavlovich, “What we’ve really shown here is that PNI puts men at a slightly higher risk of extraprostatic extension (cancer cells that are located just beyond the confines of the prostate).” Obviously, this is not a brand-new finding. However, the boldest assertion yet made by the largest study to date is that PNI only occurs in approximately 10% of Grade Group 1 patients. Pavlovich and his associates presumed that PNI gives a modest and promptly accessible marker for recognizing what men on dynamic reconnaissance will profit from more escalated observing conventions, including X-ray and hereditary tests.

Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, is of the same opinion, despite the fact that PNI evaluations are not carried out sufficiently frequently. “Along with emerging and sophisticated genetic testing of the tissue samples, may lead to more certainty in our recommendations to patients,” he says of a PNI analysis of pathology specimens.

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