What’s hot at the AUA annual meeting (Saturday)?

So the highlight of the meeting today has been a series of lectures given at the meeting of the Society for Urologic Oncology that were (to a large extent) focused on issues related to health outcomes and prostate cancer.

In the first place, Dr. Mark Litwin (from the University of California Los Angeles), in giving the annual Whitmore Lecture, talked generally about the importance of outcomes research in urologic cancers and in prostate cancer in particular. With respect to prostate cancer, his emphasis was on the degree to which it is possible to better manage prostate cancer by taking much more careful account of the impact of co-morbid conditions and related factors on the outcomes of men with low-, intermediate-, and high-risk disease. Basically, his premise was that over-treatment of prostate cancer could be significantly reduced if we accept the data clearly showing that low- and intermediate-risk patients with two or more co-morbid conditions are at minimal risk for prostate cancer-specific mortality and should normally be monitored rather than actively treated.

In a second lecture (“Natural history of prostate cancer and its implications for over- and under-treatment”), Dr. Peter Albertsen of the University of Connecticut Health Sciences Center extended Dr. Litwin’s premise by talking about the impact of the way we use Gleason grading and clinical staging to make decisions about who needs treatment. His basic premise was similar to Litwin’s … that we need to be far more selective about who needs to be aggressively treated and who needs to be carefully observed but could well have a higher quality of life if so managed. Indeed, Dr. Albertsen noted that while we are probably over-treating large numbers of men with Gleason 6, clinical stage T1c/T2a, low-risk prostate cancer, we may well also be under-treating the men with higher grade disease (Gleason 7 to 10) who commonly still progress after their first-line therapy.

The third lecture, by Dr. Peter Carroll of the University of California San Francisco (“Improving the value of PSA”) focused entirely on improving the way in which we use the PSA test to initially identify men who are really the most appropriate candidates for treatment. Yet again, the lecture was a call for a more thoughtful and patient-focused set of processes for ensuring that the right men get diagnosed and treated and that we stop unnecessary annual testing in men whose real risk for clinically significant prostate cancer is minimal.

Finally, Dr. David Miller from the University of Michigan gave his lecture on “Grassroots collaborations to improve quality in urologic oncology.” Dr. Miller described a collaborative initiative involving a total of over 100 urologists in the Midwest and on the East Coast to start to better standardize the way all members of all the practices manage their patients based on approved guidelines and best practices. Specifically, one of the examples he discussed was standardization of the application of  bone scans and CT scans among low- and intermediate-risk prostate cancer patients in line with NCCN and related guidelines.

It is clear to the writer that we are getting closer to a major improvement in the ways in which the urologic oncology community can and does focus on providing the highest possible outcomes for all men at risk for and diagnosed with prostate cancer — as opposed to being driven by the need to justify treatment in any patient who might benefit (regardless of the risks).

At the need of the day, obviously, individual factors associated with individual patients need to be taken carefully into account. Avoiding prostate cancer-specific mortality is not the only key endpoint. We also need to manage the risk of metastatic disease so as to limit the necessity for over-use of hormonal therapy. However, the outcome and the quality of life of patients appears to have returned to its appropriate place as the key objective in the diagnosis and the management of prostate cancer.

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