It is probably fair to say that readers should expect little in the way of revolutionary new information affecting the management of prostate cancer from this year’s annual meeting of the American Urological Association (AUA). However, what already appears to be evident is a continuing evolution in thinking, particularly with respect to how physicians can best discriminate between patients with low-risk, early stage, potentially indolent forms of the disease and those with higher-risk forms of prostate cancer and how to manage the lower-risk patients.
The UroToday web site has already provided commentaries on a number of sessions from the meeting of the Society of Urologic Oncologists that was held on Saturday, and rather than provide a “repeat” of that commentary, we recommend that interested readers link directly to the UroToday web site, where summaries are provided of the following presentations and discussions:
- A session on the role of imaging agents in the diagnosis and management of prostate cancer and other genitourinary cancers, with particular emphasis of prostate-specific membrane antigen (PSMA), new metabolic imaging approaches, and new agents to enhance the capabilities of PET scanning.
- A session on our expanding understanding about the role of the androgen receptor in prostate cancer, and the development of new forms of treatment based on androgen receptor blockade.
- A pro/con discussion of the value of screening for prostate cancer, with the “pro” screening position presented by Dr. Peter Scardino and the “con” position taken by Dr. Otis Brawley. It is noteworthy that during this session Dr. Brawley stated (to the surprise of the session moderator and most of the audience) that he would offer PSA testing to a 43-year-old, African-American male at an office visit.
- A pro/con discussion of the use of active surveillance as a management strategy for selected patients at low- and very low-risk of clinically significant disease, with the “pro” position taken by Dr. Ballentine Carter and the “con” position taken by Dr. William Catalona.
- A pro/con discussion of the value of 5α-reductase inhibitors (5ARIs) in the prevention of prostate cancer and the detection of patients with higher-risk disease, with the “pro” position taken by Dr. Gerald Andriole and the “con” position by Dr. Patrick Walsh.
Several of these topics evoke very strong opinions within differing segments of the urology community, and it is not surprising, therefore, that the messages delivered to patients and to men at differing risk levels for prostate cancer can be contradictory and confusing.
What The “New” Prostate Cancer InfoLink is hearing in these discussions, however, is a continuing transition from the “absolutist” positions of the 1990s (that anyone with cancer in their prostate who is under 75 should be treated immediately) to a newer and more nuanced attempt to better characterize the individual risk of each patient and then a willingness to help that patient make management decisions that “work” emotionally and clinically for each individual patient.
In that context, one very clear position was expressed by Dr. Joel Nelson of the University of Pittsburgh. Speaking at a course on prostate cancer management on Sunday morning, Dr. Nelson was blunt in saying that he now considered it to be utterly inappropriate for any low-risk patient to be given hormonal therapy as a first-line treatment for prostate cancer. He stated that — at least in his opinion — the data clearly showed, today, that treating such patients in this way did nothing to extend the metastasis-free or prostate cancer-specific survival of low-risk patients. In fact, what it clearly does do is increase the risk of earlier mortality in such patients as a consequence of the side effects of therapy. Dr. Nelson concluded his presentation on the management of patients with low-risk prostate cancer with a clear exhortation to the audience to “first, do no harm” and an emphasis on the importance of “treating the whole patient” rather than just managing the patients PSA level. This is a mindset with which The “New” Prostate Cancer InfoLink is in complete agreement.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Prevention, Risk, Treatment Tagged: | active surveillance, imaging, Management, screening
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Here’s Dr Catalona:
“The number needed to treat in order to save one life is considered to be 48:1 based upon the ERSPC data. However, longer followup and correction for contamination will bring this number down by up to 50%. In an Irish study the ratio was much lower at 15:1.”
Not only can he see clearly into the future, but a ratio of 15 men with their quality of life irreparably damaged to possibly save one life (over what period — 10 years? 15 years? 20 years?) seems to be quite acceptable. Is it?
Terry:
That would assume that all men with intervention have their QoL irreparably damaged. I don’t think that’s the case. I think the ERSPC study is too short when discussing mortality. So are radiation studies, ADT studies, etc. Ten-year studies don’t tell you much about a 20-year disease.
Tony,
I have never heard yet of any man who has had absolutely no loss of quality of life following current treatments, but as ever would be very interested to see the studies that support your view.
Many men come to grips with these losses and get on with their lives, but on the other hand there are many men whose lives have been very badly damaged and who cannot recover.
As to the ERSPC study — why is the information invalid — when does it become valid? Why do you call this a 20-year disease? Is that because there is one study that goes out 20 years? If the median age for diagnosis is in the mid 60s and the median age for death is the mid 70s, then surely a 10-year time difference is of some value?
Since “absolutely no loss” is tossed into the equation, there is no such thing and nobody should be treated cause it ain’t worth 48:1? But let’s be reasonable here … Compulsory as it is, I assume that each year tens of thousands of men whose life was extended because of treatment have to balance treatment morbidity versus survival. At least to the point that they live reasonably well and die of something else. I know that arguments will arise by this stance, and it amazes me, but I do believe that a patient as a result of treatment can have better QoL than what they would have had without that treatment. It can be argued that any QoL is better than QoD.
It isn’t unreasonable to say that a 9-year study such as the ERSPC study that made headlines in the NEJM is premature information even for a mid 60′s man, much less a 44-year-old man like I was. It is my belief that the 48:1 number has been over-stated probably as much as patients have been over-treated. Even the ERSPC states significant changes in data by adding just 3 years to the study criteria. So that said, I would bet that more than half of those who were not “saved” in the 48:1 number were NOT over-treated.
Still, this leaves a bunch of G6 75-year-old patients who went to surgery. I dunno. Perhaps it’s time to quantify these studies better by age group. I was 44 and I want to live beyond 80. Please show me the study that provides me useful information for that.