Better characterization, diagnosis of insignificant prostate cancer

The full text of a “consensus” review entitled “The contemporary concept of significant versus insignificant prostate cancer” has just been published on line in European Urology. The authors include opinion-leaders from the USA, France, Italy, Germany, Sweden and Canada.

Ploussard et al. begin by noting that the basic definition of insignificant prostate cancer has evolved over the past decade, and that its clinical relevance is based on the fact that low-grade, small-volume, organ-confined prostate cancer (PCa) may be indolent and unlikely to progress to biologic significance in the absence of treatment.

They go on to note the following generally agreed principles:

  • The most commonly used criteria to define insignificant prostate cancer are based on the pathologic assessment of the radical prostatectomy specimen and include
    • A Gleason score ≤ 6 with no Gleason pattern 4 or 5
    • Organ-confined disease
    • A tumor volume of < 0.5 cm3.
  • Established nomograms can be applied to estimate the risk of progression of low-risk on an individualized basis, but …
  • A poorly defined set of men with a high probability of insignificant prostate cancer are at risk for pathologic understaging and/or undergrading.
  • Novel and more accurate markers than can clearly discriminate between clinically insignificant and significant disease are still critically needed.

The article concludes with the clear statement that “obtaining the pretreatment diagnostic tools that can really distinguish insignificant from significant [prostate cancer] should be one of the main objectives of urologists” in the immediate future.

The “New” Prostate Cancer InfoLink welcomes this clear statement about the importance of better diagnosis and management of biologically insignificant prostate cancer from such an influential group of opinion-leaders from the urologic oncology and urologic pathology communities. The relevance of such prioritization to active surveillance as a management strategy for men with localized prostate cancer is considerable.

Having said that, The “New” Prostate Cancer InfoLink also believes that we need to be very careful to recognize that biologically insignificant prostate cancer is only one subcategory of the entire spectrum of clinically insignificant prostate cancers. The larger imperative is to be able to clearly define and identify all forms of clinically insignificant prostate cancer (based on the risk that the cancer will ever have clinical impact on the quality of life of the patient) and to be able to use that knowledge to avoid unnecessarily invasive treatment of all men with such clinically insignificant disease.

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