Dr. Adam Kibel discusses how treatment decisions should be tailored to each patient's age, overall health, cancer risk, and personal priorities, emphasizing that many men with low-risk prostate cancer can be safely managed with active surveillance. He also explains how surgery, radiation, and clinical trials each have an important role depending on the aggressiveness of the disease, with the ultimate goal of maximizing both long-term outcomes and quality of life.
Dr. Adam Stuart Kibel:
By and large, what I'm trying to do is not be aggressive. I'm trying to figure out a way not to treat the patient, to follow the patient. Now, there are some patients you end up having to treat. Some of it is psychological. If somebody's had a family member, say a parent, a brother die of prostate cancer and they have prostate cancer, it's really hard to follow psychologically. And that's actually important because family history of prostate cancer, but also family history of aggressive prostate cancer runs in a family. So you need to recognize that patient may actually have more aggressive disease.
The second group of patients are people that have very high volume disease, high volume Gleason 6. And the reason for that is they often have higher grade cancer that's just been missed. And so those patients who want to sort of investigate either using imaging or using genomic testing to see whether or not they actually have a more aggressive disease.
Other than that, most of these patients you can persuade. Or not persuade, you can discuss low risk disease. I think they all need reassurance that they can be followed safely, that the disease, if we follow it carefully, is not going to progress, that they may need treatment in the future, but at least we'll put it off for a period of time where they'll have a higher quality of life.
The radiation oncologist has to decide whether or not they're going to use hormone therapy and the favorable versus unfavorable has a huge impact on them. For the urologist, it's going to be very much predicated on how much Gleason pattern 4 they have. So if you have 3 plus a very small amount of 4, all of a sudden you're thinking, wait a minute, maybe I can put this person on active surveillance and not even have to intervene.
Somebody who has, say, higher volume disease and it's a lot of Gleason pattern 4, that patient is probably not nearly as important because you're going to treat that patient either with surgery or you're going to recommend radiation. You're certainly going to recommend some form of treatment.
Actually, I should back up on that. Patients that are significantly older who have a lot of comorbid disease, you might be looking for a reason not to intervene there as well, not because you don't care about the patient, but because the benefit to the patient is going to be minimal and the cost around complications and side effects could be quite substantial.
So for instance, an 85-year old that has Gleason pattern 7, I'm wondering why did they get biopsied. And there's nothing magic about that. Is that at 80? Is it at 75? I don't really know. It's more integrating how healthy the patient is, what are the medical problems they have, what their life expectancy is.
The data is pretty strong that life expectancy is improved by surgery for patients in their 60s. And I don't want to say when someone's 70 or 71, all of a sudden there's something magic that has changed. But once you're getting into your late 70s, 77, 78, you're not in your 60s anymore. The complication rates are higher. And I'm not talking about being unable to have the surgery, just having more problems with incontinence. I mean, everybody cares about quality of life, but an older person can be fundamentally almost disabled if we go ahead and intervene and cause complications. And so we really don't want that to happen. It's not in their best interest.
One of the most interesting things that happened to me in this regard is there was a patient I was seeing who was in his late 70s and I found myself, I was like, "I'm not sure this is a good idea." I said, "If your dad's still alive, then we would operate on you." And he said, "He's in the waiting room. Would you like to meet him?" And his dad was still alive. So it's all about longevity more than age.
I consider age very much. Again, because I think that younger patients have a longer life expectancy, so more durable treatment. I think that would favor surgery. I think very much around side effects. I think that would favor radiation. I think those are probably the two biggest factors that I think of. The amount and the aggressiveness of the cancer also influences me, though it's hard to quantify. At some point when patients have very low risk disease, I think I love active surveillance, but there are multiple treatment options that are going to be successful. As the cancer gets more and more aggressive, I get more and more worried that one treatment won't be enough. And so some people say, "Well, you're giving them radiation after surgery, that's a failure." I actually think it's wonderful to have a plan B. So if you operate on them and you take care of the cancer, they're done. And whereas if the cancer occurs, you can go ahead and give them the radiation. And that avenue, that approach isn't as available if you give someone radiation first.
There is a tipping point where you're not going to cure them with surgery. And at that point, I think it's probably better to get radiation because we know it improves life expectancy. We know that it's curative and we know that it's tolerated better. So at some point it just becomes a little silly to do surgery. I don't have a line in the sand, but I would say that at some point it's not worth the side effects, the potential side effects and complications.
We need to think about what we consider young, right? So every patient thinks of themselves as being young. I think one of the hardest things... So prostate cancer takes not years, but decades to cause people harm. So when they're talking to the urologist, the medical oncologist and the radiation oncologist who specialize in this, we're one of the first groups of physicians say, "Look, you're not going to live forever." And if your life expectancy isn't long enough, you have to back off a little bit.
So let's say we have a 50-year-old where there's a slightly enlarged one or two lymph nodes. I would consider that patient for surgery, do a good lymph node dissection. I would make sure they understood that they were almost certainly require additional therapy afterwards if, if the lymph node turned out to be positive.
Now let's imagine the lymph nodes aren't out of the primary landing zone. They're near the rectum where I can't get them out. I mean, the data is so good around using next generation hormone therapy in combination with radiation. I don't want the patient to get surgery and then be unable to progress to therapy that I know, I know, is going to go ahead and prolong their life and potentially cure them. So if I feel I can get the lymph nodes out and it's not high volume disease, I think it's reasonable. That doesn't mean we should do it on everybody but it's reasonable. But if I don't think I can get the lymph nodes out, then I feel sort of strongly that they deserve proven therapy as opposed to what I think is going to be effective.
I encourage patients to do it. I think in general, there are holes in our knowledge and we need to partner with patients in order to fill those holes in our knowledge. I don't think a patient should ever go on a clinical trial if we have a therapy that we know is going to be effective. But if we have a therapy that we know is going to be effective and we have a potentially better therapy, I think it's very reasonable. And there are plenty of clinical scenarios now where we actually don't know what is the most effective therapy. I mean, I think I've based my career on the idea that we should be treating patients with high risk disease.
When I was training patients with Gleason pattern 6, the patients that now we've managed with active surveillance was the predominant patient that we treated because the cure rate was over 90, 95, 99%. The problem with that is probably most of those patients didn't need to be cured anyway. And the patients that had really bad cancer, the kind of people who actually were at risk for dying of the disease, patients we'd say, "Oh, they're incurable," that's not true. The cure rate isn't going to be 99%, but it's going to be good. It's going to be north of 50% depending on which patient we're talking about.
And the key thing is to start layering other treatments in. So that's why I said earlier, surgery followed by radiation if we need it is not a failure if we cure the patient.
This interview was produced with the generous support of Dana Farber Cancer Institute