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During the last decade, more men with favorable-risk prostate cancer that is unlikely to cause symptoms and spread have opted for a monitoring approach called active surveillance (AS) instead of immediate treatment. AS entails routine PSA checks and prostate tumor biopsies, and the cancer is treated only if it progresses. The approach has some drawbacks, especially because repeat biopsies — which are standard for monitoring the cancer’s behavior — are expensive and uncomfortable, and carry a small risk of infection.
Now researchers are concluding that some men on AS don’t need to be re-biopsied as frequently as others. Dr. Matthew Cooperberg, a urologist at the University of California San Francisco, says a one-size-fits-all approach to scheduling biopsies “makes little biological sense,” given that prostate cancer varies so widely in terms of its behavior after diagnosis.
Current protocols call for biopsies every one to three years. But Cooperberg and his colleagues wanted to know if they could identify men who could proceed safely with an even less intensive schedule.
To find out, they reviewed data from two large AS cohorts: one is run by the Canary Prostate Active Surveillance Study, which is ongoing at nine centers in North America; the other is based at UCSF. The team focused on nearly 1,400 men who were diagnosed between 2003 and 2017 and then followed for an average of four years. They identified several factors that predict if a man’s cancer might turn more aggressive: the number of positive biopsy cores at diagnosis; PSA levels at diagnosis, and the rate at which they change over time; and a history of any subsequent negative biopsies after a man has already been diagnosed with prostate cancer.
The researchers incorporated these and other factors into an online model that shows where men fall on the risk spectrum. Findings from the research suggest that “large subpopulations of men might be able to defer additional biopsies and even many interval PSA tests,” the authors wrote. But importantly, the model doesn’t advise men as to whether they should get a biopsy or not. “It’s not a yes or no test,” Cooperberg says. Instead, the calculator “uses all the available information at hand to get a more precise assessment of risk for shared decision-making between a man and his doctor.”
Cooperberg said doctors may eventually use other types of predictive information, such as magnetic resonance imaging or tests for genetic biomarkers, to identify men who might avoid biopsies altogether. These newer tools are currently under investigation and haven’t been endorsed in clinical AS guidelines. “We’d like to do AS without any biopsies at all and tell a significant proportion of men that they’re never going to develop aggressive cancer,” Cooperberg said. “But we’re not there yet.”
“This study underscores the important research that is ongoing to help minimize invasive procedures for clinically localized prostate cancer in men who opt for 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. Garnick added that in his practice, patients who have completely stable repeat biopsies for several years, as well as stable prostate MRI studies, are followed with a combination of “PSA values, physical exam, presence or absence of urinary symptoms, and periodic MRI studies.” Under these conditions, additional biopsies are considered if findings from these other tests suggest an increase in cancer activity. The new predictive model, Garnick added, “should provide data that can help inform this decision, with the hope and anticipation that longer-term research will continue to justify less frequent biopsies.”
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The COVID-19 pandemic is bad not only for our physical health, but our mental health as well. It has killed thousands of people and disrupted our lives in terrible ways. So it’s not surprising that a recent survey finds that parents in the US are having a hard time.
Researchers did a national survey in June of 2020 of more than 1,000 parents with children under the age of 18, asking questions about mental health, insurance coverage, food security, child care, and use of health care. They found that compared to before March of 2020,
One in 10 families reported worsening mental health for themselves as well as worsening behavioral health for their children. Among those who reported that both were happening, 48% reported loss of regular child care, 16% reported a change in health insurance status, and 11% had worsening food security. Clearly, these families have been hard-hit by the economic effects of the pandemic.
Interestingly, rates of mental health problems were similar across parents of different races and incomes. However, two groups of parents had worse declines in their mental health: female and unmarried parents; and families with younger children.
This survey was done before parents had to manage the implications of a new school year, which is going to bring new stress, especially as it appears that many if not most school systems will be providing at least some of their instruction remotely. Parents again are going to have to juggle working with not just caring for their child, but being sure that they are doing — and understanding — their remote schoolwork. For many families, this is essentially impossible.
It’s also important to remember that compared to families without children, families with children are more likely to be poor — and with job losses continuing and a predicted epidemic of evictions, poor families are going to have even bigger difficulties with basic needs such as food and housing.
The implications of this are staggering. It’s not just short-term homelessness and hunger we have to worry about — it’s the long-term educational, psychological, and health effects on children. This pandemic could quite literally change the course of millions of lives for the worse.
So what can we do? Clearly, as a country we need to devote real financial resources to helping families with children, especially single-parent families and families with young children. That’s the biggest and most immediate need, and will require action from not just government but every possible source of funding.
We also need to devote resources to mental health support, making sure that anyone who needs it can get it. This won’t be cheap either, but the cost will be higher in so many ways if we don’t.
We need to find ways to look out for each other. At this moment when we need to be physically distant to prevent spread of the virus, we also need to be connected. We need to find safe ways to check in with members of our communities. That might be regular phone calls or socially distant check-ins with at-risk families, contributing to food pantries and clothing drives, volunteering to do online tutoring, donating to organizations that are helping families, and anything else that can make a difference.
Part of looking out for each other is doing everything we can to stop the spread of the virus. Along with lots of hand washing, that means that everyone over the age of 2 should wear a mask when they can’t physically distance — and that we must take physical distancing truly seriously. If we let our guard — or our mask — down, we will prolong the pandemic, with everything that means.
We need each other, more than ever.
Follow me on Twitter @drClaire
The post As family well-being declines, so does children’s behavior appeared first on Harvard Health Blog.
If you aren’t sure how to cope when a loved one is depressed, suicidal, or manic, it may be time to learn.
The number of people reporting depression symptoms shot up when the pandemic began, with a recent study suggesting depression tripled among Americans this past spring. The greater burden fell on people with fewer resources, socially and economically, and more exposure to stressful situations, such as job loss. Ongoing surveys are finding that 25% of respondents still report feeling depressed every day.
These kinds of struggles are heart-wrenching to witness. The following suggestions can help you both.
Finally, remember to pay attention to your own well-being. Consider therapy for yourself, or join a support group. This is a crucial step to lessen your own risk for depression, because caregivers have high rates of depression and anxiety. Other forms of self-care can be very helpful, too.
Numerous mental health organizations sponsor such groups and can also provide you with information on the illness, the latest treatments, and coping tips. With encouragement, knowledge, and support, you’ll feel stronger and more empowered to help shepherd your loved one through this difficult illness.
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