individualization of prostate cancer risk management

D’Amico on the individualization of prostate cancer risk management | THE "NEW" PROSTATE CANCER INFOLINK
The ASCO Post-PSA—It Just Keeps Getting Better, So Why Should It Stand Alone?

Using tools⁵ that incorporate not only the PSA level but also age, race, and digital rectal examination findings can optimize the diagnosis of prostate cancer that is clinically significant (intermediate- or high-risk). Despite enrolling less healthy men then those of average health in the United States based on Surveillance, Epidemiology, and End Results (SEER)-Medicare data,⁶ the PIVOT trial³ demonstrated a reduction in the risk of dying from prostate cancer in men with intermediate- or high-risk disease in a postrandomization subgroup analysis.

Moreover, even in the event that prostate cancer of questionable clinical significance is diagnosed (ie, very low- or low-risk disease), active surveillance protocols now exist that evaluate such men with tools such as 3 Tesla multiparametric magnetic resonance imaging (MRI) to identify occult high-grade prostate cancer (ie, Gleason score 7–10) prior to initiating active surveillance and then follow them with annual image-guided targeted transrectal ultrasound–magnetic resonance fusion biopsy of suspicious intraprostatic lesions on multiparametric MRI.⁷ With this approach, treatment is offered only when a clinically significant prostate cancer is found.

 Dr. D’Amico concludes as follows:

By including 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.