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prostate cancer

Dr. Laurence Kotz

Sunnybrook's Dr. Laurence Klotz started a worldwide debate on how best to treat low-risk prostate cancer – and won it

On a good day, Dr. Laurence Klotz hits the club early to play tennis before heading to his office at Sunnybrook.

"I feel better if I have some outlet like that," he says. "It's a great thing to be able to play a game and then go to work."

Dr. Klotz, a uro-oncologist and surgeon, has had a lot of good days lately, and, as reflected in the results of numerous studies he's led, so have many of his patients. Outcomes for men with low-risk prostate cancer, who are managed according to an approach Dr. Klotz helped develop, have shown impressive survival rates.

A 2015 Journal of Clinical Oncology-published study led by Dr. Klotz followed 993 Canadian men over a 16-year period. It found that among those managed with Active Surveillance with Selective Delayed Intervention, the 15-year prostate cancer survival is 95 per cent, with two-thirds of patients avoiding treatment entirely.

In active surveillance, men who have prostate-specific antigen levels and other factors that characterize their cancer as low-risk can avoid overtreatment by being closely monitored and with the option to intervene with selective and definitive treatment, should risk levels increase over time.

The approach, developed in partnership with radiation oncologists, Dr. Cyril Danjoux and Dr. Richard Choo, was revolutionary. It was not immediately embraced by the medical community because it challenged the prevailing view that all forms of prostate cancer warrant immediate and aggressive treatment.

"Overdiagnosis is a malady of modern medicine," Dr. Klotz says. "My message to patients is: Just because you're diagnosed with this condition, doesn't necessarily mean your life is at risk. The problem with efforts to detect many diseases early, when they are more curable, is that a lot of patients are found to have conditions that would otherwise not have been diagnosed during their lifetime, and would not have affected them in any way.  This is true of many cancers, including breast, thyroid, and kidney cancer, as well as prostate cancer. Some cancers, of course, are life-threatening. The challenge is to differentiate which cancers pose a threat and treat them aggressively, and manage the remainder conservatively, monitoring for evidence of a change in the risk of disease progression. That is the basis for active surveillance."

This concept inspired years of debate in the field of urology, and often resulted in Dr. Klotz in lively panel discussions with colleagues at conferences. Reflecting on what it took to persuade others of a different way to treat low-risk prostate cancer, Dr. Klotz says he couldn't have anticipated how central the debating skills he honed as an undergraduate member of the University of Toronto's debating club would become.

"For a year, I was president of the debating club. That experience was huge for me. You learn to think on your feet," he says. "It was fortuitous that I ended up in a debate about how to manage prostate cancer. Everything you do in life, in some way, is grist for the mill, in some way helpful."

Eventually, evidence convinced colleagues of the merits of active surveillance, which is now the global standard in the management of localized, well-differentiated, low-risk prostate cancer. Dr. Klotz was named to the Order of Canada in 2014 for establishing that standard.

"A lot of people in medicine make important contributions, but not all are recognized," he says. "I'm a very fortunate guy. I never dreamed that things would work out this way."

Back in 1984, Dr. Klotz took part in the New York City Marathon.
 


Others are less surprised that Dr. Klotz is receiving accolades. Dr. Larry Goldenberg, founding director of the Vancouver Prostate Centre , credits Dr. Klotz with branding Canada as a leading force in the field. "He's a transformative medical thinker. He's given it his all," he says. "When he sees something that is important or is a good idea, he's been able to drive it. Every machine needs a driver, and he's very comfortable getting into the driver's seat."

Dr. Robert Siemens, who leads Queen's University's urology department and is editor-in-chief of the Canadian Urological Association Journal, a publication founded by Dr. Klotz, describes his colleague as "a natural and tireless leader."

"When you think of urology across the world, one of the people you think of is Laurie Klotz," Dr. Siemens says. "There has been a frame shift. Active surveillance is now considered the gold standard for low-risk prostate cancer treatment. We have changed our approach."

While the benefits of an active surveillance approach are considerable, Dr. Klotz is quick to emphasize a doctor's role also includes finding those patients in which the cancer has higher potential to spread.

"About one-third of patients who look like they have very slow-growing non-significant cancers actually have cancers that are wolves in sheep's clothing," he says. "The challenge is to find where the wolves are."

Current and future research focuses on the use of MRI and molecular biomarkers to assist in that pursuit, he says.

Dr. Klotz envisions a time where prediction is so accurate that radical intervention for most low-risk prostate cancer patients is no longer considered a reasonable option.

Dr. Klotz credits any success he's had to his willingness to seize opportunities that came along. "There was no overarching game plan. It was a matter of being opportunistic. Each issue presented its own opportunity," he says.

Born in Toronto, Dr. Klotz knew from an early age that he would follow the example of his grandfather, uncle and father, and go into medicine. The physical component of surgery resonated with him, and that became the focus of his study.

At the time, he says, urology seemed like a neglected specialty in terms of research. He saw an opportunity to make a difference. "I was motivated by the desire to build something academic. The remarkable thing to me was that you could work away, doing research in an area that you're interested in and publishing it," he says.

"It's the magic of publishing; people actually read [the findings]. If you are persistent enough, you develop a relationship with people who are interested in the same area," says Dr. Klotz.

"I have all kinds of research projects going on right now, and I'm enjoying every minute of it."

Dr. Klotz's enthusiasm for academia is balanced by passion for his wife, Ursula, and his two children, Alex and Betsy, and by his love of jazz and sport.

He plays three instruments, including piano in the band he started, and when he's not on the tennis court, he can be found at a hockey rink or skiing. He's also a prodigious reader, having just finished Conrad Black's Rise to Greatness: The History of Canada from the Vikings to the Present. Dr. Klotz recently took a sailing trip in Sicily with his wife.

Such an adventurous jaunt is typical of Dr. Klotz, Dr. Siemens jokes. "The legend would appear to be true. He'll run an all-day clinic and then get on a plane to South America."

Dr. Klotz has brought as much energy to his profession as he has to other aspects of his life, Dr. Siemens says.

"He's credited with bringing us together and setting us on a course. Most of us would point to Laurie as being the driver. He's definitely a role model," says Dr. Siemens.


This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.

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