Improving the quality of care for men with early stage prostate cancer

It is sometimes very irritating that good and thoughtful articles appearing in the professional journals are not easily accessible to a wider lay readership. An editorial by Behfar Ehdaie, MD, in the September issue of the Journal of Urology offers a case in point.

The editorial is entitled, “Expectant management of localized prostate cancer — who, what, when, where and how?” There is no abstract, so we can’t even offer a link to that.

In this editorial, Dr. Ehdaie makes a number of statements that challenge the prostate cancer community to do a better job of ensuring the appropriate diagnosis and management of men with early stage, localized disease — and most especially those who may be appropriate candidates for “expectant management” (a term that includes both active forms of surveillance and passive forms of management like “watchful waiting” that may be appropriate for older men and those with co-morbid conditions).

Some of the key statements from Dr. Ehdaie’s editorial are given below. We trust that the Journal of Urology will forgive us for reprinting these quotations, but we believe it is important for the patient community to know that many members of the urology community are cognizant of (and feel the need to do something about) the fact that current ways of diagnosing and making decisions about the treatment of men with relatively low-risk forms of prostate cancer are less than optimal.

Since the introduction of PSA screening, the lifetime risk of being diagnosed with prostate cancer has doubled from 8% to 17%. … The sharp increase in the incidence of prostate cancer ushered an era of expanding treatment options for localized disease. Specifically it seems the adoption of new technology affects regional treatment decisions for early stage prostate cancer, inducing patients who would have otherwise opted for expectant management approaches to undergo surgery, even in the absence of evidence of superior clinical outcomes.

The contentious USPSTF recommendations [regarding screening for risk of prostate cancer] should refocus efforts in prostate cancer research to personalize management by improving risk stratification and enabling effective treatment allocation in which active surveillance, focal therapy and radical surgery or radiotherapy lie on a continuum of complementary therapies.

The challenge begins with accurate risk stratification. The rate of upgrading and up staging in radical prostatectomy specimens in patients who would have been candidates for expectant management is not trivial.

Beyond the accurate selection of men with low risk disease to undergo expectant management, the challenges are to avoid excessive delay in definitively treating those who appear to be at higher risk for progression and to avoid overtreatment of the remainder based on transient changes in PSA kinetics.

The treatment of men with early stage prostate cancer has become an important public health issue, and offers urologists an opportunity to seize this pivotal moment and collaborate to evaluate the effectiveness and value in the treatment of our patients. Real problems in systematic errors with routine TRUS guided biopsy need to be improved, and the infectious and bleeding complications associated with expanded biopsy strategies represent an imperfect solution. The use of imaging for targeting biopsies would bring prostate cancer diagnosis into line with the biopsy technique used for the detection of almost all other solid tumors, and improve the detection of significant cancers and the prediction of insignificant disease. … Finally, focusing efforts to improve the education of our patients will be essential to alleviate the stress associated with over detection and to improve the quality of care we deliver to patients.

We do not have solutions to all of the problems that Dr. Ehdaie accurately points out in his editorial … but it is at least gratifying to note the clear recognition of the problems, and the fact that there is a real opportunity to start to address them.

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