Several urologists have crossed their arms to change a word of the prostate cancer guidelines

The National Comprehensive Cancer Network (NCCN) has been accused of removing the “priority” status of Active Surveillance (AS) in low-risk prostate cancer. Guidelines..

AS has been listed as a priority since 2019, and this change will be comparable to radical prostatectomy and radiation therapy in this patient population.

Edward “Ted” Schaeffer, MD, PhD, chair of the NCCN Prostate Cancer Guidelines Panel, defends this change as a “minor adjustment” that helps patients by encouraging more discussion about low-risk patient options. Did.

“My personal impression is that as the risk group grows, so does the nuance,” said Schaefer of Feinberg School of Medicine in Chicago, Northwestern University. “Individual cases need to be considered more strongly and discussed with patients, and patients need to be involved in a shared decision-making process. I don’t think there are any changes to the guidelines. Active surveillance is listed first. It has been, but it is still. It is listed as an option. “

He emphasized that the guidelines dated September 10 still claim that AS is “favorable” for very low-risk prostate cancer.

Matthew Cooperberg, MD, a urologist at the University of California, San Francisco (UCSF), sees this change as a “step back” in a quarter-century campaign to reduce overdiagnosis and overtreatment of low-risk prostate cancer. increase.

Dr. Stacy Loeb, MD, professor of urology at New York University and the Manhattan Veterans Medical Center, said:

“In the United States, active surveillance has been slow and heterogeneous,” she said. “It is well established that active surveillance is safe for men with low-risk prostate cancer and offers important benefits in reducing overtreatment and maintaining quality of life.”

The NCCN guidelines “have no legal weight,” Cooperberg said. “It’s very easy for clinicians to point this out and say:” Active monitoring for low-risk illnesses. “

Patient groups were divided on their potential impact on their components.

Mark Lichty, chair of the AS Patient Group Active Surveillance Patients International, said that a decline in AS status could discourage some men from joining AS. “We have seen significant advances in combating low-risk overtreatment. [prostate cancer]And I hope that changes in this guideline will not delay that trend, “he said.

Tom Farrington, a consumer member of the NCCN Panel and founder of the Prostate Health Education Network, said Tom Farrington, a patient with advanced prostate cancer, said the change was particularly unsuccessful for black men who were as unsuccessful as white men in AS. Said it was important. He said the change would lead to more debate about options for low-risk patients.

However, Cooperberg said, “The problem of different AS results in African-American men has not definitely been resolved. Many believe that adjusting clinical factors does not really make a difference. I argued.

According to NCCN guidelines that are very influential in decisions made by practitioners, health insurance companies, and Medicare:

Patients meet the criteria for low-risk disease if all of the following are met: clinical T stage below cT2a (including less than half on one side), tumor grade group 1 (Gleason ≤ 6), and prostate-specific antigen 10 ng Antigen (PSA) levels below / mL.

Very low risk criteria are more stringent. The grade group and PSA are the same, but the tumor must be cT1c (tumor identified by needle biopsy on one or both sides, but not palpable). In addition, less than 3 prostate biopsy fragments or cores may be positive, each fragment / core has less than 50% cancer, and PSA density should be less than 0.15 ng / mL / g. ..

In practice, the distinction between low-risk and ultra-low-risk illnesses is not important, said Brian Helfund, MD, director of urology at the North Shore University Health System in the suburbs of Chicago.

“I’m surprised that the guidelines distinguish between preferred management strategies,” Helfand said. “As a primary management strategy, all grade group 1 tumors (regardless of very low or low classification), regardless of the core lesions of prostate cancer, are proactively based on a low risk of disease progression. I think we need to monitor. “

The panel did not vote formal. Schaeffer raised the temperature over the phone to reach consensus in favor of the change, which only two panelists opposed. (A formal vote at the NCCN is only required for legal reasons when recommending a drug.)

The changes were published on September 10th, but were overlooked until September 28th.

At that time, Dr. Daniel Lynn, MD of the eagle eye, who was responsible for urological oncology at the University of Washington in Seattle, discovered the change and Kooperberg. Posted For fellow urology leaders on Twitter.

The reaction was fierce and immediate, with an indictment led by Cooperberg of UCSF, one of the centers that supported the development of AS 25 years ago. This is a close monitoring strategy for low-risk diseases currently accepted by 55% of qualified US patients. For the approach.

Some urologists have accused the NCCN of making a decision in a closed room.

“It’s a democratic process. There’s no secret agenda,” Schaefer said. The panelists returned the proposed changes to the center and elicited comments, he added. Only two panelists opposed the change in priority status.

One was Todd Morgan, MD, Head of Urological Oncology in Ann Arbor’s Michigan Medicine. “The NCCN could definitely be more transparent-there’s no reason not,” he said. “I think most of this guideline is outstanding and evidence-based. This one mistake is far from what is really a state-of-the-art guideline.”

Cooperberg conducted an online survey of 341 Twitter followers asking if the NCCN should regain the “priority” of low-risk men. 86.2% said yes, 4.4% said no, and 9.4% said they needed more discussion on this topic.

“We must be aware of the strengths and limitations of the NCCN. The NCCN is basically a consensus of expert opinion. People call it” excellence, “” said Lawrence Crotz, MD, “Father of AS” at the University of Toronto. Called “Gender-based Opinion”. Celebrity with white hair. This is not the last word on this topic. It may reflect the opinion of some experts who are not sold with the idea of ​​false monitoring. “

Schaefer was blinded by the repulsion. He will be praised by a group of experts at major cancer centers for the introduction of the first US guidelines for PET-based diagnostic imaging and the first oral testosterone blocker, Orgovyx, for progressive disease. I was hoping for.

He said the guidelines are not a rulebook, but fluid over time.

Howard Wolinsky is a Chicago-based medical freelancer who wrote this blog. About his cancer journey for Today’s MedPage Since 2016. He is the author of the just-released book and Containment and Elimination: American Medical Association Conspiracy to Destroy Chiropractic..