The Mind

Abstract

Since the late 1980s, the widespread use of PSA for opportunistic prostate cancer screening allowed treatment at an earlier stage, and at least in part, was responsible for a 30-40% decline in prostate cancer mortality (1). However, the stage migration favoring early localized disease, inevitably also brought the downstream effects of a diagnosis, including the enthusiasm for aggressive treatment of virtually all men who are diagnosed, driven by a myriad of forces: -inability to precisely determine the long-term risk of harm without treatment, -factors other than disease characteristics such as the limitation of using evidence to inform practice (2), and perverse incentives that often drive physician recommendations (3), commensurate with the adoption of robot-assisted laparoscopic radical prostatectomy (4, 5).Consequently, considering the relatively high prevalence and ease of detecting, mainly low-risk cancers (6), the benefits of PSA introduction to clinical practice came with the substantial cost of over diagnosis and over treatment of many men, raising the question of whether PSA screening is associated with more harm than benefit (7).Considering the lead-time of 6-12 years afforded with PSA testing and the generally long natural history of prostate cancer (8), high-level evidence supports the low risk of harm without treatment from favorable-risk prostate cancer in older men.In fact, while an estimate of number needed to screen (NNS) or number need to treat (NNT) at a single point in time can be misleading, and also sensitive to comorbidity status at baseline, using a bootstrap approach the 95% CIs for NNS can be as wide as 323 to 1052 and NNT 11 to 35 to prevent one prostate cancer death at >10 years (9).In the PSA era, Parker et al. (10) estimated the 15-year risk of prostate cancer mortality to be 0-2%, for men aged 55-74 years diagnosed with a Gleason score of 6 and managed conservatively, such as due to considerable lead time, curative intervention is unlikely to improve health for those with a <20 year life expectancy.Even for those patients that to a large extent would not be considered favorable risk by today's classification schemes and did not have screen-detected prostate cancers, when aged 65 years, no overall, cancer-specific, or metastatic-free survival benefit was associated with surgical treatment when compared with no treatment at 12 years, suggesting the probable absence of a cancer-specific survival benefit well beyond 12 years in The Scandinavian Prostate Cancer Group Study 4 (SPCG-4) (11).

<p>Prostate cancer “super-active surveillance” era opened by vascular targeted photodynamic therapy</p>

“…While current guidelines support active surveillance (AS) as the best treatment option for low-risk prostate cancer,3,4 it does not always remain indolent and up to 60% of the patients will undergo radical treatment within 5–10 years 5–9. A primary concern is the underestimation of cancer grade that could compromise long-term cancer control, 10 which drives many physicians to recommend more aggressive interventions. Moreover, some of these patients are not comfortable with AS and want to be more active in their surveillance.…”

“…Moreover, some of these patients are not comfortable with AS and want to be more active in their surveillance. For these patients, focal ablation is an option to make surveillance “super-active”, and despite adding morbidity to surveillance, it may fill the gap between surveillance and radical definitive treatment, a halfway between hypothetical undertreatment and overtreatment 10,11…”

“…As shown by Reis and Carter, the psychological burden in terms of anxiety over the uncertainty, or fear of losing the opportunity for a cure (which are directly related to health perception and care), leads to up to 18% of patients at AS to be overtreated with no evidence of disease progression 10,25…”

“…Thus, these techniques rely on imaging exam ability to properly stage cancer. Prostate MRI has shown high sensitivity and negative predictive value to clinically significant prostate cancer diagnoses 2,10,39…”

Super active surveillance for low-risk prostate cancer | Opinion: Yes

“…Thus, the debate of AS is anything more intense and relevant than ever. As we described before, AS is particularly susceptible to perceptions and bias, life intricacies of both patients and their treating physicians (13). Compliance in AS demands a commitment, significant intellectualization, and conviction to ameliorate the anxiety motivated by thoughts, either own or from else, that the diagnosed cancer may mutate and go wild.…”