Eye of the beholder—Tales from Prostate Cancer Active Surveillance Development

For the March 2021 issue of BJUI Compass, we have our first paper on active surveillance for prostate cancer—a major part of my clinical practice. I have been around long enough to have observed this idea start as a research concept that needed IRB protocol and informed consent protections, to being part of guidelines-based clinical practice. Meanwhile, the practice is an important part of how we manage prostate cancer screening efforts that yield low-grade cancer. The tools for effective screening and active surveillance have grown and have significant overlap—secondary biomarkers, MRI imaging, fusion or transperineal biopsy, etc. A favorite memory from my early practice years was from the Winter meeting of the Society of Urologic Oncology in 2005 (I think) when it was a smaller research-oriented retreat. We had back-to-back 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 Toronto2 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 sub-specialization 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 Hunderford from her book in 1878. It is also an album and track title from 1988 from one of my favourite jazz-fusion artists Chick Corea. I was the bass player for the Davidson College Jazz Band from 1986–1990 and enjoyed playing works from Corea and his various band and solo projects. I have always wondered how jazz artists and other pure instrumentalists come up with album and track titles when there are no song lyrics, repeating choruses, or stories being told. Perhaps the concepts are only broad in nature and Corea works the phrasing with a separate track called “Beauty” (my favourite—a good tune for the OR), and “Eye of the Beholder,” “Passage,” “Forgotten Past,” “Amnesia,” and others. I recommend you check it out—a true fusion-jazz concept with powerful rhythms, creative structures, solid melodies, and a lot of instrumental improvisation. I outlined several parts of this editorial in January of this year only to learn of Corea's passing on February 9th, 2021 at the age of 79. We lost an amazingly talented and pioneering musician and happy to pay him tribute with this article. His career goes back to the 1960s and included 23 Grammy Awards.

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