What’s new in the Journal of the Canadian Urologic Association?

The April issue of the Journal of the Canadian Urologic Association offers the interested reader access to the full texts of a small number of topical articles. None of them could be considered “game changing” in terms of current prostate cancer management today … but certainly thought-stimulating.

The first of these articles is a consensus statement, issued by Klotz et al. on behalf of the Canadian Urological Association, on the appropriate use of 5α-reductate inhibitors (5-ARIs, e.g., finasteride and dutasteride) in the management of benign prostatic hyperplasia and in the prevention of prostate cancer. The statement is a response to the decision by the US Food & Drug Administration, announced on June 9, 2011, to include information in the Warnings and Precautions section of the labels for 5-ARIs about the increased risk of high-grade prostate cancer associated with the use of these agents. The bottom line to this consensus statement is that, “In the Canadian context, the panel believes that there is value in preventing low-grade cancers and decreasing the burden of prostate cancer.” The panel therefore makes a number of detailed recommendations about the appropriate use of 5-ARIs in the prevention of prostate cancer in well-defined, appropriately selected, and appropriately monitored patients.

The second article is by Rodriguez et al. and focuses on the potential need for improving the risk classification of men initially diagnosed with localized forms of prostate cancer. The authors carefully review the current risk classification systems (e.g., those like the D’Amico system, the NCCN system, and the CaPSURE system). Almost all such systems effectively classify patients into one of three categories — low-, intermediate-, or high-risk. However, there are small but significant distinctions between the various systems. Rodriguez et al. contend that in fact we need a system with somewhat greater discrimination in which patients can be categorized into one of five different risk categories:

  • Very low-risk
  • Low-risk
  • Low intermediate-risk
  • High intermediate-risk
  • High risk

The “New” Prostate Cancer InfoLink can certainly see merit in this proposal. However, what we would really like to see is consensus around the international use of a single risk classification system. In an ideal world this might indeed have five categories, but in our view international adoption of a single risk classification system would be more beneficial than worrying over-much about whether that system had three, four, or five risk categories.

A third article, by Tyldesley et al., addresses the appropriate referral of patients at high risk for biochemical progression after first-line radical prostatectomy for a consultation with a radiation oncologist and the appropriate identification and management of those patients who should or should not receive immediate, adjuvant radiation therapy. Tyldesley et al. review available data from relevant patients treated in British Columbia between 2005 and 2007. They conclude that “Not all patients with adverse prostatectomy pathology
were seen by a radiation oncologist post-prostatectomy, and very few received adjuvant radiotherapy despite almost half of them having risk factors for relapse.”

The need for immediate adjuvant radiation therapy (as opposed to salvage radiation therapy) is a complex and controversial topic. The one thing that everyone seems to agree on is that when radiation therapy is needed after surgery, earlier is better than later. What is much harder to get consensus about is who actually does need immediate adjuvant radiation. It is probably fair to say that too few patients do get a referral to a radiation oncologist to have that discussion.

A final article is one by McCormack et al. on the relative merits of thinner needles (the standard 18G needles widely used today) or slightly wider needles (16G needles) in the conduct of TRUS-guided needle biopsies. McCormack and his colleagues make a reasoned argument that using 16G needles might improve accuracy in the diagnosis of prostate cancer because more tissue would be available for pathological examination. Whether this argument is really justifiable is harder to assess. In his editorial comments about the papers in this issue of the journal, Klotz states that he personally intends to stick to using the 18G needles, combining this use with the appropriate and selective use of MRI scans to identify areas of the prostate that need to be biopsied.

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