The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, September 23, 2014

The Billion Dollar Question: Aggressive or Not?


The billion-dollar question facing the approximately 240,000 men in the U.S. diagnosed each year with prostate cancer is: Do I get treated? Or not?

Overtreatment of prostate cancer is both a major problem and extremely costly both financially and physically.

Financially, because of the high cost of radical treatments and physically because most treatments can cause unpleasant and long-lasting side effects. Overtreatment was also the most important driver of the 2012 decision by the United States Preventive Services Task Force to recommend against routine screening for prostate cancer. Approximately 30-40% of men who have previously undergone surgery or other radical invasive treatment likely had indolent, slow-growing tumors that would never have become a threat to the man’s lifespan or health.  However, there is hope.

At the AACR-PCF conference in January 2014, Dr. Matthew Cooperberg, a urologic oncologist at the University of California, San Francisco (UCSF) warned, “If we don’t fix the problem of prostate cancer overtreatment, we will lose screening.” And losing screening would almost certainly mean more prostate cancer deaths—reversing a nearly 45% decline in mortality rates since screening started.

The crux of the problem is the supposed uncertainty about the accuracy of current predictors of tumor aggressiveness, leading physicians and patients alike to opt for a better-safe-than sorry approach that in turn results in extensive overtreatment. However, the vast majority of prostate cancers do not change their stripes. Cancers that appear to be slow growing when diagnosed are unlikely to cause serious problems during a man's lifetime. On the other hand, cancers that appear high-risk at diagnosis are indeed more likely to behave aggressively. So identifying them remains vital in deciding whether to treat or not to treat.

Some physicians and researchers are currently combining this clinical information with genetic information. Adding biomarker tests to clinical predictors further improves the identification of which prostate cancer patients could undergo Active Surveillance versus immediate treatment.

Now that Active Surveillance is a valid and safe way to treat low-risk prostate cancer men should not shy away from PSA screening.  We can’t return to the era prior to PSA screening.  Back then half the men diagnosed had cancer that was already outside the prostate.

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