Brian: We’re so glad you’re joining us today for the conversation with Dr. Ali Kasraeian. I am not Danielle Lee, clearly, I’m Brian Middleton, I’m actually filling in for today, and Dr. Kasraeian, thank you for letting me fill in.
Ali Kasraeian: Yeah, thank you for joining us today. It’s always a pleasure having you on.
Brian: Awesome, and to all of the listeners, if you have a question for the doctor over the next hour, at any point in today’s show, you can always call in to our phone lines, 904-340-1045, that’s 904-340-1045.
Doctor, what are we talking about today?
Ali Kasraeian: So, today we are talking about a fresh off the press study, off the New England Journal of Medicine, talking about prostate cancer, which is near and dear to my heart. It’s basically a follow up of a study from several years ago, basically comparing prostatectomy with versed observation for prostate cancer. So, basically comparing removing the prostate vs just observing people with prostate cancer over time.
This is a study that previously had been published after about 5 years of follow up, or several years ago, after 12 years of follow up, and now we’ve got approximately 20 years of follow up, and we’re talking about the results. It actually really didn’t see much difference in overall survival, and prostate cancer specific survival, which is very surprising to us, as prostatotectomists. Actually, a couple other studies recently came out over the past several years, one was in the … [inaudible 00:01:41] … Journal of Medicine, recently that compared observation with surgery and radiation therapy that came out of the United Kingdom, that followed a large number of patients, about 87,000 patients recently that didn’t show differences either, when broken down there’s some differences that were note, so we’re going to talk about all of these things, and break down the study, and to find it tells and see if that truth actually stands the analysis of the data.
To start of the show to help me out, is a good friend to the conversation, a dear mentor of mine, Dr. David Albala, who’s joining us from New York. He’s the Chief of Urology at Cross Hospital in Syracuse, New York, the Medical Director of Associate Medical Professionals, and the former Director of Robotic Surgery at Duke University, who’s a world renown robotic prostatectomist and a urologist. He actually was involved in the first laparoscopic nephrectomy years ago, so not to date him, he’s not that old, but he is just very, very accomplished and his thoughts and insights are always very profound, anywhere that he speaks.
So, doc, thank you for joining us!
David A: Ali, it’s great to be back. We’re getting some of your Florida weather up here. It’s nice and sunny, and warm in Syracuse, which is a nice change from all the snow that we get most of the year.
Ali Kasraeian: Well, I’m glad that you’re having wonderful weather. So, let me ask you, what do you think about this study?
David A: I think it’s an interesting study, and for those men that have prostate cancer, obviously, there are many choices that you can have for treatment. We know that prostate cancer is extremely slow growing, and because of that, it’s a disease process that for patients that have very favorable disease, we can actually observe these patients and just follow them along with what we call active surveillance, because we know that it’s such a slow growing tumor that many of these patients will live a perfectly normal life, without any form of treatment whatsoever. But the standard treatment for prostate cancer over the years have been radiation therapy, where men come in and sit under an xray machine, and xray’s are delivered, radiation therapy delivered to the prostate to kill the tumor, or surgical intervention, where we go in, whether we do it robotically or with an open technique, take the prostate out.
For years, we thought that these forms of treatment, whether it’s radiation or surgery had better outcomes in men that have prostate cancer, compared to essentially doing nothing, and we’ve learned I think, from this study, that there are patients that will benefit from observation or active surveillance. So not everybody needs to be treated actively, and I think what’s interesting is when you break down the patients, and the patients that have high aggressive disease vs low risk disease, patients that have low risk disease are going to do well with just observation.
There’s no question that if the disease is not very aggressive, we can follow it, and the thought process was, if you have high grade disease, or aggressive disease, those are the patients that need to be treated. What the study showed is there clearly was no difference in the low risk group, which we I think assumed, but what’s surprising was in the high risk group, that patients that were observed did just as well as those that had surgery. So that was sort of the little twist of things. Patients that had intermediate risk, actually did better with surgical intervention compared to observations, so I’m not sure how to put it together, other than, perhaps the study didn’t have enough patients to look at those high risk patients over a long enough period of time … [crosstalk 00:05:59] … Go ahead.
Ali Kasraeian: One of the things looking at that specific thing, and when this trial come out, it came out on July 13th, and when this came out, I was kind of looking over it, and two things popped out in the study to me, one, for a study that they planned on following for such a long time, I thought, and this was a study that started in 1994, and they included patients in terms of their accrual time until January of 2002, and they’ve been following now for about again almost 19 1/2 to 20 years.
There was 19.5 years of follow up, which is amazing, and they had about 731 patients, so they randomized, which is also amazing. So, basically for our audience, this is the greatest type of study you can have, where people come and they don’t know what they’re going to get, and they are randomized to whether they get observation or whether they get a surgical procedure. Which, I’m always amazed at people that sign up and then get into the study, because it’s just a very brave thing, brave contribution to Science, to do that. It’s a very pure way for us to go, because you assume and you hope that it’s very unbiased.
David A: There’s no question. I think over the years we’ve learned that we don’t have to be as aggressive as we once thought in treating these patients. I think prostate cancer, for the audience, is very different from breast cancer, or colon cancer, or pancreatic cancer. It’s a slow growing tumor, and as far as I can think, it’s the only tumor where potentially active surveillance or observation is offered as a treatment modality … [crosstalk 00:07:56] …
Ali Kasraeian: You know what? I think they’re saying breast cancer is catching up to prostate. I think it’s the only thing, where it seems like prostate cancer is learning a lot from breast cancer, and I think recently, over the past few years, breast cancer is learning for certain lower risk, kind of [inaudible 00:08:08] … things like that, they’re beginning to embrace the idea of active surveillance for those lower risk cancers.
David A: Right, and I think that we’re learning more and more. Cancer biology in the prostate’s really exploded over the past few years. Now we’re doing genomic testing these tumors, trying to understand on a molecular level, how these tumors work, and how they potentially grow, and kill people. We now know, that some of them don’t do that at all, and that’s what’s unique. This is a very unique study because of the randomization of patients into a surgery arm and an observation arm.
You mentioned how brave some of these people are, when you think about it, if your physician tells you that you have cancer, and they say we are doing a study, and we’re not going to treat you, I’m not sure a lot of patients would sign up for that, and it’s to be commended that these patients did sign up for this, and really gives us a chance to look at a pure way on how each of these modalities is going to be successful.
Ali Kasraeian: Yeah, so for me, one of the things that I was thinking about when I initially looked at the study, I was taken by the initial idea that, “Would 731 patients?” Does that seem like a little bit too few patients, where you would kind of break it down into 360 “ish” patients on each arm, so basically when they broke this down, there were 364 patients in the surgical arm, where they did a prostatectomy, and there are about 367 patients …