The optimization of risk assessment for management of prostate cancer

According to information from the Medical University of Vienna (in Austria) and Vienna General Hospital, researchers at these centers have been developing what they believe to be a smarter set of strategies for assessing prostate cancer risk and subsequent treatment, when this is needed. The strategies are outlined in a media release issued yesterday (and also discussed on the ScienceDaily web site).

As we have stated many times before, the appropriate use of the PSA tests to assess individual risk for prostate cancer is quite certainly a matter of controversy, but that doesn’t make the PSA test a bad test. It just means we need to understand how to use it more wisely.

To quote Dr. Shariat, in the Medical University of Vienna media release:

Although the PSA is not an ideal marker, it is still the best diagnostic biomarker across the whole of oncology. At a younger age, i.e. [in men] around 40 to 45 years, it is very useful in terms of predicting the risk of prostate cancer. The data also confirms this. Since the PSA screening test was introduced, deaths from prostate cancer have fallen by 40 per cent. So the question isn’t about whether PSA screening should be carried out or not. It’s more about doing it cleverly.

What Shariat and his colleagues have been doing is applying the principles of personalized medicine to avoid overly aggressive use of unnecessary biopsies and thus further avoid unnecessary over-treatment and the consequent risks for the side effects of over-treatment — primarily incontinence and/or erectile dysfunction.

The media release is (unfortunately) rather light on some of the details that we might have liked to understand better, but here is the basic approach being taken by Shariat and his colleagues:

  • When the patient is relatively young and his PSA level is only slightly raised, he is initially, actively monitored with regular follow-ups. The goal is to avoid unnecessary procedures while ensuring that any malignant development of a tumor is reliably detected.
  • If the PSA value is so elevated that a biopsy needs to be considered, the PSA test is initially repeated within 12 weeks, and additional tests with other (unspecified) biomarkers and mathematical calculation models are factored into the decision-making process.
  • New molecular methods in imaging and pathology, along with the mathematical modeling, is used to create a comprehensive biological profile of the cells — enabling precise risk assessment for the individual patient by the diagnostic team, accurate localization of the tumor, and accurate determination of its molecular structure.
  • This series of processes facilitates better estimation of whether treatment is needed and would be useful, and how likely it is that the patient will respond well to different types of treatment.
  • If the diagnostic/prognostic model recommends surgery as the therapy of choice, it is also strongly recommended to the patient that surgery is carried out at a specialist center that conducts this type of surgery with a high level of experience and frequency.

Compared to the USA, the population of Austria is, of course, relatively small at about 8.5 million (more like the populations of the states of New Jersey or Arizona in the USA). There are something like 4,700 new patients diagnosed with prostate cancer in Austria each year, and about 1,146 men actually die from prostate cancer in any one year, so a strategy like this is much more feasible to execute on a national level than it would be here in the USA.

Having said that, it would be interesting to know a little more about the “new molecular methods and imaging” — and the mathematical modeling systems — being used by Shariat et al. in the work-up of patients who appear to be at risk for prostate cancer, and the long-term outcomes of men evaluated and treated (or monitored but not treated) using this process over time.

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