BY RALPH BLUM
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.
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.