D’Amico on the individualization of prostate cancer risk management

In an interesting article in the September 2014 issue of The ASCO Post, Dr. Anthony D’Amico argues in favor of a future in which individualized approaches to risk will replace PSA screening alone as a means of determining who actually needs to be biopsied and (if necessary) receive treatment for clinically significant prostate cancer.

Dr. D’Amico is a thoughtful and highly regarded member of the U.S. prostate cancer research and treatment community. Many of our readers will have come across his name in association with the so-called D’Amico system for categorization of prostate cancer into low, intermediate, and high risk levels. His current article takes account of three relatively important developments over recent years:

  • The long-term results of the European Randomised Study of Screening for Prostate Cancer  or ERSPC trial, data from which, in its most recent follow-up report, have now shown that (to quote Dr. D’Amico) initial PSA testing can be used “to reduce mortality from prostate cancer by 21 percent in an average-risk population” with only 781 men needing to be screened and 27 men needing to be treated (at 13 years of follow-up) to avoid one prostate cancer death. As Dr. D’Amico goes on to observe, the current prediction is that at 25 years of follow-up one might expect only 262 men to need to be screened and 9 men to be treated to prevent a single prostate cancer-specific death.
  • The continuing evolution of multiparametric MRI scanning as a method to help to determine which patient really need to go on to be biopsied, “If costs for this imaging technology can be moderated” (which is, regrettably, a rather large “if”).
  • The potential of the scoring system based on the Prostate Imaging and Reporting Archiving Data System (PI-RADS) to is starting to bring some real logic to the process of determining who needs a biopsy based on the index of suspicion for clinically significant disease that can be determined based on multiparametric MRI and other data.

Dr. D’Amico concludes as follows:

By including these additional parameters in the biopsy decision-making process, we can achieve the long-term benefits of PSA screening in reducing death from prostate cancer through early detection while minimizing the diagnosis of disease — at any given point in time — that is unlikely to progress to metastatic disease if left untreated. In this way, overdiagnosis and overtreatment will become significantly less likely.

What Dr. D’Amico does not address in his article, however, includes some very important issues related to such an approach:

  • When is it appropriate to initiate risk-based testing of individuals for prostate cancer?
  • Is the use of baseline PSA testing of men in their 40s (as opposed to annual screening) an appropriate component of this approach?
  • What is the role of active surveillance and other forms of monitoring in limiting the risk for over-treatment?

In saying this, we are not criticizing Dr. D’Amico for failure to address these issues … we are merely noting that they are components in the development of an overall approach to risk management over time.

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