An increasing number of patients are seeing only early cases of prostate cancer

An increasing number of patients are seeing only early cases of prostate cancer

Watch and wait. This practice is still peculiar when it comes to cancer, but for some tumors, such as the prostate, kidney and breast, the concept of active surveillance is gaining more and more supporters.

New studies and methods have brought more and more safety to this method, as there is no need for surgery, chemotherapy or radiotherapy.

Men with prostate cancer benefited the most from this option. A study released in May by the American Congress of Urology shows that in the past seven years, the number of patients with early tumors on active surveillance in the United States has more than doubled – from 26.5% to 59.6%.

In these cases, monitoring means monitoring with tests, such as an MRI, PSA (prostate specific antigen) and digital rectal examination, and regular consultations with small, low-risk tumors and only treating them if there are signs of developing cancer.

Many cases of prostate cancer diagnosed with PSA are low-risk. This means that it is small and confined to the prostate and is not aggressive according to the international classification system (Gleason score).

According to urologist Ronnie Fernandez, Vice President of SBU (Brazilian Society of Urology), the option for active surveillance has also grown in Brazil, is well established in international studies and incorporates SBU guidelines.

“When you classify the patient well before suggesting any treatment, you are certain that he is at low risk, and the chances of success are over 90%, which is equivalent to the conventional treatment which is a prostatectomy. [retirada da próstata] and radiotherapy.

Among the criteria are for the patient to have a PSA of less than 10 ng/mL and only a small portion of the prostate is affected. Tumor genetic testing has also been used, which can indicate whether it is high-risk or low-risk.

Surgery can cause side effects such as urinary incontinence and erectile dysfunction. “When you suggest surveillance with security and trade-offs [a troca] He does not suffer from incontinence and, mainly, does not suffer from erectile dysfunction, patients agree to do so,” says urologist Carlos Sacumani, editor-in-chief of the Urological Information Bulletin, for the SBU regional magazine in São Paulo.

For Sacomani, in Brazil, this option has limitations when it comes to SUS patients. “In a country with difficult access to primary care, and early cancer diagnosis, the question is whether we can catch the patient in the initial stage. Active surveillance in advance requires adequate monitoring, and the patient must be able to make an appointment, and take the necessary tests. This It is the big challenge.”

Fernandez remembers that monitoring is indicated only if the patient undergoes counseling and examinations every three months, digital rectal examinations and MRIs every six months, and scheduled biopsies. “You have to turn surveillance into debt. If you can’t afford it, you better deal with it.”

According to the urologist, active surveillance for kidney cancer has also been approved, in cases where tumor masses are smaller than 4 cm and in elderly patients. “We follow up and do imaging tests. If the mass grows more than 0.5 centimeters per year, we do.”

In breast cancer, the active surveillance protocol has been studied extensively in ductal carcinoma in situ, which are small calcifications found within the breast milk ducts. Studies show that less than 50% of these cases will become invasive tumors, meaning they can spread to other areas and require surgery and other treatments. The rest, in theory, can only be monitored. But there are still surefire ways to tell them apart.

Therefore, according to Dr. Carolina Soliani, member of the Brazilian Society of Breast Medicine, there is no scientific support for not performing surgery on young and healthy patients with this type of tumor. “In very elderly patients, who have comorbidities and have small disease at the site, we are evaluating the benefit of surgery.”

According to breast pathologist Jose Luis Bevilacoa, in these cases, it has been suggested to “relax” treatments, avoiding radiotherapy, chemotherapy, or even more drastic surgeries. “As clinicians, we should always consider the intensity or severity of treatment in the face of a patient’s comorbidities,” he says.

Today, there are three main studies worldwide that follow more than 1,000 women with in situ breast cancer who are under active surveillance. The largest, with 932 patients, began recruitment in 2014 and ended in 2020. The group was divided between those who underwent surgery and those under the active surveillance protocol. Patients will be followed up for ten years and annual mammograms will be performed.

“We need these results to understand tumor behavior and have confidence in the indication.” [da vigilância]. The question remains today: ‘I wonder if we’re not going to expose this patient to have a disease [câncer] disease and its progression? ‘ says Carolina Soliani.

Massage therapist Rosangela Bettencourt, 63, was diagnosed with ductal carcinoma in situ nearly 20 years ago and was referred for a bilateral mastectomy (removal of the breast). But after two years on the SUS waiting list, she gave up the surgery and left for TCM treatment.

“It was a tough decision, but when I learned that after my mastectomy I still had to go through about eight procedures, I gave up and bet on other methods,” he says. She continues to monitor microcalcifications with checkups and medical consultations, but says they’ve decreased and are under control.

In the case of low-grade colorectal cancer, the Watch & Wait protocol, as it is known internationally, was developed by Brazilian physician Angelita Habr-Gama in the 1990s and was able to prevent the patient from undergoing major surgeries, which can result in Infections and sexual and urinary dysfunction, as well as the need for a colostomy [bolsa coletora de fezes].

The protocol explained that patients with this tumor respond well to radio and chemotherapy, without the need for surgery. But they need to schedule medical appointments for a physical exam and lab and imaging tests.

Surgery is only done if the tumor reappears, which occurs in about 25% of cases, according to Rodrigo Oliva Perez, MD, a gastroenterological surgeon at Oswaldo Cruz Hospital (SP). He is the principal investigator of a multicenter study that will determine the best treatment strategy for patients under the protocol.

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