Dr. Claire de la Calle

I think it's really important to first start by looking at the PROTECT data to understand the long-term outcomes of untreated versus treated localized prostate cancer, especially because PROTECT is one of the few randomized clinical trials that we have in localized prostate cancer management.

And as you all know, the study randomized around 1,600 men, and 24% more or less of those had intermediate-risk disease.

and the patients were randomized to active monitoring or radiation therapy or radical prostatectomy, and at 15 years of follow-up, there's really no difference in all-cause or prostate cancer-specific mortality between all three groups, which is fairly surprising when thinking about cancer.

Now, the rates of metastatic disease were significantly higher in the active monitoring group, around 9% versus around 5% for both the

radiation and surgery groups, but active monitoring is very different from active surveillance.

Active surveillance is, of course, a much more intensive monitoring of the cancer, and I think that's important.

Patients will often ask me about this trial, and that's something I think needs to be stressed.

Now, from the active surveillance literature specifically, Dr. Guillaume Plussard and his colleagues published a great systematic review and meta-analysis specifically comparing the outcomes of low-risk active surveillance patients and intermediate-risk active surveillance patients.

And they basically showed that in an unselected

intermediate risk group, those patients had greater risk of metastases and a greater risk of prostate cancer-specific mortality.

But the key word here is unselected.

They focused their analysis then in the subset of patients that only had gray group 2 prostate cancer.

And in that subset, metastasis-free survival was similar when compared with the low-risk patients.

So

It really means that appropriate patient selection is key when considering active surveillance in an intermediate risk patient.

Yeah, just like you said, patient selection is so important for intermediate-risk patients.

It's more important, I think, than for the low-risk patients because these intermediate-risk patients are more likely to develop metastases and die of prostate cancer.

And like you said, it's a very heterogeneous group with a very wide spectrum of disease biology, in fact.

When a patient with intermediate risk walks into my clinic, it could be a patient with indolent disease or lethal disease.

Really, every end of the spectrum is represented in this group.