Prostate Cancer: 'Change in Mindset' Needed


Hello. I am Dr. Gerald Chodak for Medscape. This week I want to talk again about prostate cancer screening and treatment and the controversies surrounding the US Preventive Services Task Force (USPSTF) guidelines.

An interesting and well-done article by Scardino and Vickers, published in [AUA News] in March,and a report by Dr. Ian Thompson at the Genitourinary Cancers Symposium raised the question of whether it is time to rethink how we manage this disease. The enthusiasm for screening has clearly resulted in overdiagnosis and overtreatment. While it may reduce mortality to some extent, the USPSTF concluded that the harms of overscreening outweigh the benefits, and they recommended against screening.

Many people are obviously upset by that recommendation, thinking that by abandoning screening we will now shift back to a higher mortality. So the question being raised by these smart individuals is, can we find an approach that modifies what we have been doing and shifts us back to a favorable outcome with more benefits than harms?

Drs. Scardino and Vickers make the following suggestions. First, clearly for men with low-risk disease, we are overdiagnosing and overtreating that problem. Men over age 70 are not benefiting from treatment of low-risk disease and should be offered active surveillance. Second, we need to stop screening men who have little chance of benefiting: those with a life expectancy less than 10 years, and particularly older men. Nearly half of men over age 75 are undergoing routine screening. That clearly needs to change. For men under age 60 with a prostate specific antigen (PSA) < 1 ng/mL, the likelihood of dying from the disease during the remainder of their life is very low, and so limited screening in that group is warranted.

It makes sense to reduce the number of biopsies being performed because most men do not have prostate cancer. If you select a cutoff of 3 ng/mL and a patient has a level exceeding that, repeating the PSA within a few months before proceeding to a biopsy makes sense, because roughly 4 out of 10 men will have a drop in their PSA level back to < 3 ng/mL. Also, using the PSA velocity is not a reliable way to recommend biopsies in men with a PSA < 3 ng/mL, as it leads to a greater chance of finding low-risk cancers.

Finally, we come to the issue of active surveillance. Clearly for men over age 65 with low-risk disease, the chance of benefiting from treatment seems to be small. We need to be more cautious about counseling these men that their chance of benefiting will not be outweighed by their chance of being harmed by therapy.