THE "NEW" PROSTATE CANCER INFOLINK

It is becoming increasingly clear that the prevention, treatment, and management of prostate cancer is at an intellectual as well as a practical, clinical crossroads.At a pro/con session earlier this afternoon, speakers discussed what have now become three of the most controversial issues in the management of prostate cancer:

• Can and should we use drugs like finasteride and dutasteride to prevent prostate cancer in appropriately selected patients?
• Can and should we use PSA to “screen” for prostate cancer?
• Can and should we use supplemental testosterone therapy to manage quality of life in men diagnosed with and treated for prostate cancer?

In each case, it has become clear that consensus has shifted from the absolute “yes” or “no” positions of just a few years ago to “maybe,” with a great deal of emphasis on the when and how as opposed to the “just do it” (or don’t do it) perspective.

Finasteride and dutasteride will now never be approved for the prevention of prostate cancer. However, there is clearly a subset of men who, in careful discussion with their doctors, can reasonably come to the decision that the supposed risks associated with the use of such drugs may significantly be outweighed by the potential benefits of preventing — or at least delaying the onset — of prostate cancer. And since these drugs are easily prescribed, it is likely that they will be for such patients.

Similarly, although the idea of mass, annual, population-based screening of all men for prostate cancer cannot be justified on the basis of data from trials published to date, there is certainly a strong argument for some type of PSA monitoring — particularly in men with one or more well-defined risk factors. And the question is therefore more focused on how we use PSA testing appropriately to optimize the potential to identify men at the greatest levels of risk while simultaneously seeking new and better tests for prostate cancer risk.

In the third case, there appears to be a growing consensus that — with appropriate caution and careful monitoring — supplemental testosterone is a perfectly reasonable form of treatment for many (but probably not all) men with low serum T levels, regardless of whether they have no prostate cancer, untreated, low-risk prostate cancer, or prostate cancer that has been successfully treated.

In each case we are moving back toward a mindset in which decisions about such issues need to be taken on an individual basis after discussion between doctor and patients and with an appreciation of the risks involved for the specific, individual patient.

The “New” Prostate Cancer InfoLink sees this process as a “good thing.” The “one size fits all” approach is seldom a good idea in the management of healthcare. There is too much interpersonal variation between individuals to think that what is good for Simon must inevitably be good for Saul too.

Will this need to actually think through and discuss what is appropriate for individual patients put more pressure on physicians to make time to have these discussions? Yes, it will, and it may take a while for the urology community to adapt to a new reality.

Filed under: Diagnosis, Living with Prostate Cancer, Management, Prevention, Risk | Tagged: dutasteride, finasteride, Prevention, PSA, screening, supplement, testing, testosterone |