Three important editorials


The October issue of the Journal of Urology carries three editorials that we consider to be very important to the world of prostate cancer — for professionals and patients alike.

In the first editorial, entitled “Practice makes perfect,” Joseph Smith (of the Department of Urologic Surgery at Vanderbilt University) addresses the fact that “Repetition of tasks and experience are recognized and accepted parameters that improve performance in many disciplines.” He goes on to discuss the application of this fact to surgical experience and the increasing emphasis placed on the quality of the outcomes achieved by individual surgeons as a criterion for selection by patients.

Using a series of very apt analogies, Smith notes that, for example, Tiger Woods was clearly born with a talent for playing golf, but that his skill level has been vastly improved by dedication, practice, and experience (particularly under pressure). Equally, surgical talent and volume are not enough to make a great surgeon. Practice and dedication are the other essential components.

Smith offers two key messages to his peers:

  • “[S]urgeons must act in the interest of their patient.”
  • “The responsibility of a surgeon is to ensure that his or her training, experience and abilities offer probable outcomes in line with the expections of an informed patient.”

He also offers a key message to potential candidates for surgery:

  • “A baseball pitcher can throw a perfect game but not for an entire season. A bowler can roll a 300 but not every game. … Likewise, it is an unrealistic expectation for a surgeon to have perfect results and outcomes with every case.”

What’s the bottom line? The very best prostate cancer surgeons work at being good at what they do, but they aren’t perfect. They are human. Even Tiger Woods has “off days.”

In the second editorial, David Neal (of the Department of Oncology at the University of Cambridge in England) asks the question, “Can we accurately identify men with low risk prostate cancer?” His answer to this question is in the negative because (at least at the moment), “We cannot accurately discriminate among degrees of risk, at least for the individual.”

Neal goes on two review data from two papers published in this issue of the Journal: the papers by Barocas et al. and Ercole et al. (Both these papers were previously addressed on this forum in news reports on August 26th.) His basic conclusion is that these two articles are “useful additions to the literature” and show that “a significant number of men with newly diagnosed prostate cancer have a disease that poses a low degree of risk to future health, and that these men should be offered the opportunity to adopt a conservative management approach.”

Finally, in the third editorial, Ian Thompson (of the University of Texas Health Science Center at San Antonio) and colleagues make the argument that, “It’s time to abandon an upper limit of nromal for prostate specific antigen.” They argue that the  fundamental barriers to abandoning the upper limit of 4.0 ng/ml as an upper limit of normal for PSA levels are twofold: precedent and current laboratory reports.

Thompson and his colleagues point out that, based on data from the Prostate Cancer Prevention Trial (PCPT), we now know that only in men with a PSA of < 1.0 ng/ml is prostate cancer consistently curable, and that at this PSA level about 50 percent of the cancers were clinically significant. By contrast, at a PSA level of > 4.0 ng/ml more that 25 percent of the cancers identified were no longer curable.

They go on to make a strong case for the incorporation of individualized prostate cancer risk assessment into normal clinical practice, which is a concept entirely endorsed by The “New” Prostate Cancer InfoLink. We know how to do this. The data are available to support this concept. And such individualized patient management is customary in many other areas of medicine.

The “New Prostate Cancer InfoLink believes that these three editorials represent a continuing acceptance on the part of the urology community that high quality of risk assessment, avoidance of unnecessary treatment, and high quality of treatment when treatment is necessary should now be seen as essential to the management of men at risk for prostate cancer.

3 Responses

  1. Assessing whether patients who have been recently diagnosed are low-risk for tumor growth is feasible, but never a sure bet, especially if they are not closely monitored through active surveillance.

    Still even with active surveillance, it appears to me that urologists can only guess at the real pathology, unless the patient decides to opt for surgery so a post-op biopsy can occur with the prostate under the microscope.

    Equally important, as in my case, only surgery, with its clearer up-front glimpse inside the pelvic region, can determine if there are other complications involving nearby organs such as the bladder or seminal vesicles.

    In my case it was discovered only after robotic surgery that I needed to have my bladder neck reconstructed, or else I would have ended up a “urological cripple.”

    This phrase came up in a conversation between my surgeon and contributing author and with my wife, as I elaborate in my new book, Conquer Prostate Cancer: How Medicine, Faith, Love and Sex Can Renew Your Life.

    In another friend’s case, it was discovered after robotic surgery that his cancer has spread from his prostate to his seminal vesicles. Had his doctors not identified that after his surgery, they might not have explored the extent to which his lymph notes were similarly involved.

    In turn it would not have been clearly mandated that he would benefit from additional treatment such as chemotherapy and hormone therapy which followed his surgery. That treatment was no fun but he suffered willingly, knowing that those additional approaches would increase his prospects for greater longevity.

    It may well be that risk assessment coupled with active surveillance can help patients avoid “over-treatment.” But at this time prostate cancer surgery can reveal more than other modalities like radiotherapy or active surveillance. This isn’t theory. As I’ve demonstrated, it really has happened.

  2. That third important editorial (Thompson) really has me confused. What does it all mean? If you go below 4.0 PSA as an upper limit of normal, that’s below average PSA for anyone over the age of 55 (Mayo Clinic study: age 50-59 – PSA 3.5; age 60-69 – PSA 4.5).

    Should you biopsy 2/3 of all men over 50, or abandon PSA (the best marker in oncology) as biopsy criteria?

  3. In the actual editorial, Thompson gives detailed examples of what he means by “individualized prostate cancer risk assessment.” He is absolutely not suggesting we biopsy everyone with a PSA of 1.5 ng/ml (for example). What he is saying is that there is an obligation on the physician to discuss the options carefully with the patient and make a decision together (as compared to the continuing current situation in which biopsies are the norm for everyone with a PSA over 4.0 ng./ml, or 2.5 mg/ml, depending on the physician’s interpretation of the available guidelines).

    If you can get a copy, I suggest you read the actual editorial. Unfortunately we cannot post this on the site because of copyright restrictions.

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