Over the past decade, there has been a dramatic shift in prostate cancer detection and management. This can be attributed to a number of factors:
Recognition that PSA screening SAVES LIVES
Despite what the US Preventative Services Task Force (USPSTF) initially suggested, PSA screening DOES, in fact, save lives in men ages 55-69. We know now that the USPSTF based their recommendations on the results of the US-based PLCO study, which was greatly flawed.
Most of the men in the control ‘no screening’ arm who were supposed to NOT be screened actually DID in fact have screening. Due to significant contamination of the data, the results of the study have been rendered meaningless. An update from the USPSTF earlier this year acknowledged that there were significant errors in that trial.
A large multicenter European trial as well as another one from Göteborg, Sweden BOTH demonstrated a significant reduction in prostate cancer mortality with PSA screening.
The key issue with PSA screening is not whether or not men should be screened.
The concern instead should be to avoid over-treating the slow-growing, low grade, clinically insignificant cancers that are often found through routine PSA screening. By subjecting those men to unnecessary side effects and morbidity of treatment they don’t need, it defeats the entire purpose of PSA screening.
The intent of PSA screening should be to find and treat the life-threatening, aggressive prostate cancers that will kill men if left untreated.
Significant improvement in prostate MRI technology
Multiparametric prostate MRI provides impressive details of the internal architecture and anatomy of the prostate. This can reveal ‘lesions’ or abnormalities within the prostate that are suspicious for cancer and provide a roadmap for targeted prostate biopsy.
We no longer need to (nor should we) perform random ultrasound-guided prostate biopsy with the inherent 30-50% chance of MISSING the cancer. What other organ have we continued to randomly stick needles into HOPING to hit the cancer if it is present? Answer: None.
Development of MRI/Ultrasound 3-D Fusion Prostate Biopsy Technology
This technology creates 3-D renderings of the prostate using MRI images and ultrasound images and then merges the two together. This provides real-time 3-D imaging of suspicious lesions within the prostate and enables accurate sampling.
Several large studies have documented a significant improvement in prostate cancer detection with this approach compared to standard ultrasound-guided biopsy. This can also have a tremendous impact on how we treat prostate cancer.
Prostate MRI along with MRI/US fusion biopsy provide very specific anatomic detail about prostate cancers that enables better consideration for potential less-invasive treatment options such as focal therapy.
Recognition that low grade prostate cancer is indolent
Low-grade prostate cancer, or what is described pathologically as Gleason score 6, is what we refer to as “clinically insignificant”, and has negligible risk of spreading or causing mortality. Several retrospective reviews have demonstrated that patients with low-grade prostate cancer who underwent surgery had nearly zero risk of prostate cancer mortality.
Based on this, some have argued that Gleason 6 prostate cancer should be called ‘pre-cancerous’ or dysplasia, but it has certain biologic and molecular features that will keep its designation as cancer.
Acceptance of active surveillance as a safe, reasonable approach for men with low-grade prostate cancer
This was formerly referred to as “watchful waiting” but we now monitor cancers more actively. We now recognize that we (urologists as a community) have been over-treating low grade prostate cancer for a long time, subjecting patients to the unnecessary side effects and morbidity of treatment with minimal impact on their long-term survival.
We need to provide individualized treatment, tailored to each patient’s particular disease and situation.
These changes in prostate cancer detection and management provide the perfect storm for consideration of less invasive treatment options including ablative therapy and focal therapy.