key: cord-1044194-1d5ymjqh
authors: Davis, John W.
title: Eye of the beholder—Tales from Prostate Cancer Active Surveillance Development
date: 2021-03-27
journal: BJUI Compass
DOI: 10.1002/bco2.80
sha: 7709aa0bafdcb835d0d08ebdc1968aac761577d3
doc_id: 1044194
cord_uid: 1d5ymjqh

nan

when it was a smaller research-oriented retreat. We had back-toback speakers on prostate cancer with different messages that had a bit of humorously conflicting conclusions. The first speaker was Andrew Vickers from Memorial Sloan Kettering Cancer Center, 1 presenting on the learning curve of radical prostatectomy. At the end of that lecture, everyone was probably thinking to themselves: "Oh no, I need to go home and double my radical prostatectomy case volumes, or I might be labelled as a low volume surgeon." The next speaker was Lawrence Klotz from the University of Toronto 2 who presented his maturing data and successes with active surveillance for low-risk prostate cancer. At the end of that lecture, everyone was probably thinking to themselves: "Oh no, I need to go home and cut my radical prostatectomy volumes in half, or I might be labelled as an over-treating/patient-harming surgeon." This era of active surveillance data was a breakthrough in the field-previous presentations of less mature data were often attacked for being dangerous and risking pT3 cancer progression. This lecture was one of the early ones that was mature enough to be convincing that low-risk prostate cancer was a different entity.

Of course, by 2021, we now have strong guidance on the surveillance management of low-risk prostate cancer and can focus treatments more on intermediate to high-risk patients. In support of Dr Vickers findings, we have trended towards more surgical subspecialization and higher case volumes to improve quality of results.

In this same area of case selection and referrals, however, there are low and favourable-intermediate risk patients who are appropriate candidates for active surveillance, but can be predicted to be at high risk of progression and need for future treatment. These patients are an interesting group to talk with, as when you spell out the choices and bigger picture, you often get patients gravitating towards one of the two ways of thinking about it: (1) treat it now at a lower risk/ volume category with higher cure rate chances and a young age to make a good functional recovery, and (2) take advantage of the next 3-5 years on active surveillance free of treatment-related side effects. There is no right or wrong approach here. The dilemma is sort of a "pay it now or pay it later" situation, but I have also used the phrase "beauty is in the eye of the beholder," to illustrate the point that some active surveillance vs treatment decisions are subjective, and patients may look at the value of each strategy differently.

For another bit of a rabbit trail diversion, the phrase "beauty is in the eye of the beholder" is credited to an author Margaret Wolfe 

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