So … as a couple of readers have already realized … the sheer quantity of new and interesting data at the meeting is enormous, and your reporter is going to have to select what he tries to covers with care, ‘cos there’s no way to cover it all!
From a patient perspective, there was a really interesting series of presentations this morning related to the diagnosis of prostate cancer and the application of active surveillance. There are no on-line abstracts for most of these presentations.
It began with a presentation by Dr. Ian Thompson (University of Texas Health Sciences Center at San Antonio) entitled “Understanding the U.S. Preventive Task Force recommendations on prostate-specific antigen screening.” Dr. Thompson was at pains to point out that whatever one’s personnel reactions to the recommendations might be, one needed to understand that the point that they were making was accurate: that mass, population-based screening for prostate cancer was associated with a significantly higher potential risk for harm to an individual patient than it was with potential benefit in terms of improved survival. From that point on, Dr. Thompson focused on the need to be able to better identify and select those men who were most likely to benefit from PSA testing and (if needed) from subsequent biopsy, with the full recognition that, even in these men, active surveillance or even watchful waiting might be an appropriate management strategy.
In the second presentation, Dr. Chris Parker from the Royal Marsden Hospital in the UK discussed the current use of active surveillance at his institution and at other clinical centers in the UK. Dr. Parker believes that the application of active surveillance is aleady relatively widespread in the UK. What was also interesting was his perspective that high quality MRI scanning can now be used as effectively as repeat biopsies in the monitoring of many men on active surveillance protocols. While other speakers in the sesion were not ready to go as far as Dr. Parker, it was clear that the Royal Marsden team had developed an active surveillance management protocol with which they are extremely comfortable and that is designed to avoid the excessive (and in their opinion unnecessary) need to re-biopsy patients over time.
Three further presentations addressed the tools available to aid in the practical application of active surveillance. Dr. Peter Choyke (the National Cancer Institute) spoke about the growing evidence supporting the application of MRI enhanced TRUS-guided biopsies (but he was less confident that Dr. Parker about the simpler use of MRI scans to monitor men on active surveillance). Dr. Matt Cooperberg (University of California San Francisco) spoke about the development of new biomarkers. His conclusion was that progress is being made but that, as yet, new biomarkers had still to prove, in a very practical way, that they could substantially improve the ability to accurately project risk for clinically significant prostate cancer and the potential for progression by comparison with available tools such as the CAPRA score. Finally, Dr. Jesse McKenney (Cleveland Clinic) offered an interesting set of comments on the potential need for a really serious re-think of the Gleason grading system, given all the known problems in the variation in interpretations of certain unusual pathological factors that, currently, may lead to a particular tissue sample being graded as Gleason 3 or Gleason 4, with concomitant implications for the patient’s Gleason score and clinical risk.
The first morning session concluded with a presentation of the Sunnybrook active surveillance re-biopsy data that have already been discussed on this site.
What was very clear to all attendees was that the academic urologic oncology community is now extremely comfortable with the idea that we should be trying to significantly lower the risk of harms associated with PSA testing, biopsies, and actual treatment of men with potentially low- and very low-risk prostate cancer, whle at the same time optimizing the probability that men with intermediate- and high-risk disease are identified as early s possible and treated appropriately. On the other hand, there was also a clear recognition that, in the community setting (at least in the USA), the majority of clinical practices are far from ready to embrace these strategies, and there is much more work needed to persuade community-based urologists and radiation oncologists that active surveillance is an appropriate and effective strategy by which to defer or avoid unnecessary treatment for men with low- and very low-risk prostate cancer.