When to Screen, Biopsy, and Treat Prostate Cancer
When to Screen, Biopsy, and Treat Prostate Cancer
Dr. Vickers: What do the current guidelines say about who we should be treating and who we should not be treating, in terms of the stage, grade, PSA level, and so forth?
Dr. Carlsson: What is most concerning is that here in the United States, the use of active surveillance has not been widely embraced for low-risk tumors as much as it has in Europe. In Sweden, for example, as many as up to 50% of men with low-risk tumors are being put on active surveillance as the initial management. Studies show that 99% of urologists and radiation oncologists would advise a man with low-risk disease to undergo active treatment here in the United States. That is where we need a treatment shift.
Dr. Vickers: "Yes, you have prostate cancer. It's not a bad one. It's very unlikely to cause you problems. We'll follow you. As soon as we have any indication this could be a harmful cancer, we will treat you, but not at the moment." What are the criteria that you would use, in terms of stage, grade, PSA, to say this to a patient?
Dr. Carlsson: For example, a man who has a Gleason 6 tumor, a PSA level less than 10 ng/dL, and a clinical stage T1c -- that would be a perfect example of a man who is at very low risk of dying from the disease.
Dr. Vickers: Do you find any men who have palpable disease that you would put on active surveillance?
Dr. Carlsson: Sure. The concept of active surveillance and watchful waiting are close to each other, and if the man is old, you can certainly watch a patient with higher-stage cancer as well, initially, knowing that treatment is an option over time.
Dr. Vickers: Right. Some men do need treatment. At the moment, in the United States, we know that a lot of men are being treated at very-low-volume centers, where the number of radical prostatectomies by surgeons who do them is 3 per year. High-volume surgeons have better outcomes.
Who Should Be Treated? Not Treated?
Dr. Vickers: What do the current guidelines say about who we should be treating and who we should not be treating, in terms of the stage, grade, PSA level, and so forth?
Dr. Carlsson: What is most concerning is that here in the United States, the use of active surveillance has not been widely embraced for low-risk tumors as much as it has in Europe. In Sweden, for example, as many as up to 50% of men with low-risk tumors are being put on active surveillance as the initial management. Studies show that 99% of urologists and radiation oncologists would advise a man with low-risk disease to undergo active treatment here in the United States. That is where we need a treatment shift.
Dr. Vickers: "Yes, you have prostate cancer. It's not a bad one. It's very unlikely to cause you problems. We'll follow you. As soon as we have any indication this could be a harmful cancer, we will treat you, but not at the moment." What are the criteria that you would use, in terms of stage, grade, PSA, to say this to a patient?
Dr. Carlsson: For example, a man who has a Gleason 6 tumor, a PSA level less than 10 ng/dL, and a clinical stage T1c -- that would be a perfect example of a man who is at very low risk of dying from the disease.
Dr. Vickers: Do you find any men who have palpable disease that you would put on active surveillance?
Dr. Carlsson: Sure. The concept of active surveillance and watchful waiting are close to each other, and if the man is old, you can certainly watch a patient with higher-stage cancer as well, initially, knowing that treatment is an option over time.
Dr. Vickers: Right. Some men do need treatment. At the moment, in the United States, we know that a lot of men are being treated at very-low-volume centers, where the number of radical prostatectomies by surgeons who do them is 3 per year. High-volume surgeons have better outcomes.
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