09/04/2019

Risks of active surveillance for men with intermediate-risk prostate cancers

Chances are good that at some point you or someone you know will have hip replacement surgery.

I can say that with some confidence because it’s a common operation that’s becoming more common all the time. An estimated 300,000 total hip replacements are performed each year in this country, and that number is expected to nearly double by 2030. The most common reason is osteoarthritis, the age-related “wear-and-tear” type of arthritis that can be difficult to treat with medications or other non-surgical approaches.

If you’ve had a hip replacement yourself, you may have experienced some things that surprised you. For example:

    Despite having major surgery on the largest joint in the body, you probably stood up and started walking on it within a day or two.
    You probably were only in the hospital for a few days.
    The improvement in the arthritic pain is usually noticeable right away.
    Despite all that, after discharge from the hospital, the physical therapy visits seemed to go on forever.

In fact, it’s routine after hip replacement surgery to have extensive physical therapy — also called rehabilitation therapy, or “rehab.” This usually consists of a series of outpatient appointments with a physical therapist. These visits usually take place two or three times a week for a month or more to help you work on strengthening, stamina, and balance.
Is home rehab just as good?

A new study calls into question the way people receive rehab after hip replacement surgery.

The researchers presented their findings at a recent meeting of the American Academy of Orthopaedic Surgeons. They described how, among 77 people having hip replacement surgery, half were randomly assigned to meet with a physical therapist 2 or 3 times a week for 2 months. The rest were instructed on particular exercises to be performed on their own at home for two months.

Here’s what they found:

    One month after surgery, there were no major differences in the individuals’ ability to function as assessed by their ability to sit, walk, and use stairs, or other measures of daily activities.
    Six months after the surgery, there was still no difference in results.
    Changing the routine physical therapy from supervised appointments to exercising at home could be accompanied by a significant reduction in the cost of care. And the convenience is an extra bonus.

Of course, this may not work for everyone. Many people who have hip replacement surgery cannot return home right away, especially if they live alone and have to climb a number of stairs right away. For them, surgery is followed by a stay at a rehabilitation facility, where they receive supervised physical therapy on a daily basis until they’re strong and steady enough to get around safely at home.

Another consideration in how post-op rehab is provided is the notion of “pre-hab” — that is, when surgery can be planned in advance (such as a hip replacement for arthritis), an exercise program prior to surgery may be useful. Those willing and able to exercise before surgery may have an easier time with home rehab.
So, now what?

This new research should be considered preliminary because it included only a small number of study subjects and the results were presented at a medical conference; they have not yet been published in a peer-reviewed medical journal. Additional research will likely be needed to confirm the findings and to identify those who are most likely to do well with self-directed rehab.

But, if the findings of this new study are confirmed, it’ll be welcome news for the thousands of people having hip replacement surgery who may no longer be asked to trudge back and forth to physical therapy appointments. For parents of teens, “addiction” is a scary word. It brings to mind all sorts of things we never want to have happen to our children, from overdoses to arrests — and so we talk to our kids about drugs and alcohol. But is there another addiction we should be worrying about, too?

The Merriam-Webster definition of addiction is “a strong and harmful need to regularly have something (such as a drug) or do something (such as gamble).” Using that definition, you could make a real argument that many teens are becoming addicted to their mobile devices.

You could make the same argument about their parents — and plenty of other people, too.

Common Sense Media recently published a report on a survey they did on 1,240 parents and teens (620 parent-child pairs). The findings are not a big surprise to anyone who, well, looks up from their phone. They found that:

    50% of teens feel that they are addicted to their mobile devices (and 28% think that their parents are too)
    27% of parents feel that they are addicted to their mobile devices (and 59% think that their teens are too)
    66% of parents feel that their teens spend too much time on their mobile devices — and 52% of the teens agree with them
    48% of parents and 72% of teens feel the need to respond immediately to text messages and other notifications
    69% of parents and 78% of teens check their devices at least hourly
    half of parents and a third of teens at least occasionally try to cut down the time they spend on their devices.

This is pretty powerful. Parents and teens are in agreement that their devices have a hold on them.

Now, I don’t want to seem to say that constantly checking Instagram is the same as shooting heroin. Clearly, it’s not. I also want to be careful to point out that clinicians are not quite ready to use the word “addiction” when it comes to technology. And there is also very limited research on the long-term effects of having our faces stuck to our phones. But there is real cause for concern.

Devices displace. It’s that simple. We only have so much bandwidth when it comes to awareness, interaction, and memory; multitasking is, ultimately, simply paying less attention to more things. And when you pay less attention, there can be consequences.

For teens, there are consequences when it comes to learning (it’s hard to lay down new memories and learn new material when you are distracted), social relationships (it’s hard to build or maintain them, and to hone social skills, when you are on your phone), sleep (which can have tremendous impacts on both mental and physical health), safety (like using the device while driving or crossing the street) and the general and important ability to sustain attention.

For parents, besides all the consequences above (which apply to adults, too), there are concerns about how devices literally get in the way of parenting. Researchers at Boston University have done some very interesting observational studies of parents and children, and found (here’s a shocker) that when parents are on their phones, they interact less with their children. Given that so much of relationship-building and cognitive development depends on interaction, the implications — which may not be fully seen for years — could be significant, even profound.

We need more research to understand all those implications. But in the meantime, the message is clear: devices need to be used thoughtfully, and with care.

Every person and every family is different — and so every approach to a healthy balance is going to be different. But there are three times when device use should be as close to zero as possible:

    When it impacts safety, like when driving or walking. This is where the zero comes in.
    When attention is important for learning or performance, like at school, doing homework, or in the workplace.
    During social gatherings, like meals or parties — or simply hanging out or having a conversation. It’s one thing to use devices to connect with people who are somewhere else; it’s entirely another to use devices when those people are sitting next to you. Our connections with other people are crucial for our health and well-being; we cannot let our devices undermine those connections.

Check out the Common Sense Media report. Talk about it as a family. Do some soul-searching. Make some ground rules. Make sure that every day, you spend time paying full attention to the world around you — and to the people you love.

Watch the short video below. It’s powerful — and brings the point Men diagnosed with slow-growing prostate tumors that likely won’t be harmful during their lifetimes can often avoid immediate treatment. Instead, they can have their tumor monitored using a strategy called active surveillance. With this approach, doctors perform periodic checks for tumor progression and start treatment only if the cancer begins to metastasize, or spread. Active surveillance has become popular worldwide, but doctors still debate which groups of men can safely use this strategy. Some doctors offer it only to men with the lowest risk of cancer progression. Others say that men with intermediate-risk prostate cancer can also make good candidates.

A new study now shows that intermediate-risk tumors are more likely to metastasize on active surveillance than initially expected. “Most men do fine on surveillance, but we have detected a higher risk of metastasis among intermediate-risk patients over the long term,” said Dr. Laurence Klotz, director of the active surveillance program at the University of Toronto’s Sunnybrook Health Sciences Centre, where the study was based.
Taking a look at intermediate-risk prostate cancer

Sunnybrook’s active surveillance program dates back to 1995, so it allows for remarkably long-term follow-up. Nearly 1,000 men have enrolled in the program so far. The majority have low-risk prostate cancer, which means their prostate-specific antigen (PSA) levels don’t exceed 10 nanograms per milliliter (ng/mL) and their Gleason scores are no higher than 6. (Gleason scores describe how aggressive a tumor sample looks under the microscope.) About 200 men in the study have intermediate-risk prostate cancer. Usually, intermediate-risk cancer is determined by a Gleason score of 7 or a PSA level higher than 10 ng/mL. However, these intermediate cancers can also be divided into lower- and higher-risk categories, depending mostly on how much higher-grade cancer shows up in the biopsy.

The new analysis shows that 30 of the 980 men evaluated in the study eventually developed metastases (or areas of spread). Of those men, two had low-risk prostate cancer, while the other 28 had either been diagnosed initially with intermediate-risk tumors, or were upgraded to that category while they were on active surveillance. The risk of metastases was therefore 3% overall for all the men evaluated, but roughly four times that for the intermediate-risk men, specifically. The median time to metastasis was 8.9 years, meaning that for all the men whose cancer spread, half experienced it within 8.9 years of diagnosis and half experienced it later than that.

According to Dr. Klotz, the likelihood of metastases was mainly dependent on the amounts of Gleason 7 cancer in the prostate, and whether a man’s PSA levels doubled quickly. He expects that a few more men in the study will develop metastatic cancer with age and longer-term follow-up.
Is active surveillance right for some intermediate-risk men?

Though metastasis is a major problem when it occurs, Dr. Klotz emphasizes that roughly 80% of the intermediate-risk men in the study have so far avoided that outcome. And these men, he said, are also avoiding cancer treatments that would otherwise have a significant effect on their quality of life. Still, Dr. Klotz urges caution when selecting intermediate-risk men for active surveillance. “Based on these findings, I would strongly encourage that these men be further evaluated with magnetic resonance imaging and/or genetic biomarkers,” he said.

“These longer-term data shed new light on the ultimate outcomes of men considered for active surveillance who had components of higher-grade cancer when they were initially diagnosed, or who were found to have it on subsequent biopsies while on active surveillance,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Many variables factor into whether active surveillance should be considered for intermediate-risk men. Dr. Klotz highlights MRI and biomarkers, but medical diagnoses, family history, and the patient’s emotional capacity to address a higher likelihood of metastases should all be considered.”

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