In addition to today’s resource, please review:
- Who Should We Screen For Prostate Cancer With The Prostate Specific Antigen (PSA)
Posted on September 21, 2024 by Tom Wade MD - Link To And Excerpts From The New York Times’ “Too Many Older Men Are Still Screened for Prostate Cancer” With Links To Additional Resources
Posted on September 19, 2024 by Tom Wade MD
Today, I link to and excerpt from Localized Prostate Cancer — Then and Now. NEJM. Oliver Sartor, M.D. Published March 11, 2023
N Engl J Med 2023;388:1617-1618
DOI: 10.1056/NEJMe2300807
VOL. 388 NO. 17.
All that follows is from the above resource:
When the ProtecT trial was initiated, the typical approach of screening men for prostate cancer was to assess the PSA level, biopsy those with an elevated PSA, and treat the cancer. That simplistic approach has dramatically changed in the wake of evidence that has been gathered since 1999. PSA testing is no longer the norm. In many clinics, PSA testing is not done at all,
and the legal consequences of not testing are diminished, given that guidelines now embrace patient-centric informed decision making.4 Unfortunately, such an evaluation is often problematic at best, given that busy primary practitioners are faced with an array of issues and have only limited time to discuss the nuances of the decision and the possible outcomes.Today, if a patient has an elevated PSA level, data suggest that the clinician may use multiparametric magnetic resonance imaging (MRI) to selectively biopsy only patients with a score of
3 to 5 on the Prostate Imaging Reporting and Data System (PI-RADS), which classifies a lesion on a scale from 1 to 5, with higher scores indicating a higher suspicion of cancer. A targeted
biopsy appears to be sufficient to diagnose tumors in grade groups 3 to 5.5 Additional riskstratification methods beyond clinical stage, PSA level, and Gleason score are also readily available. Transcriptomic assays (also known as genomic classifiers) can provide important prognostic information and help guide treatment decisions.6 Germline genomic assessments are also endorsed by expert groups in patients with higher-grade tumors or selected family histories.Prostate-specific membrane antigen (PSMA) positron-emission–tomographic (PET) scans are now approved to better assess staging in patients with unfavorable intermediate or high-risk localized disease. In certain circumstances,
PSMA PET scans may also be useful in determining appropriateness for biopsy.7 Once risk stratification regarding the tumor is complete, clinicians can undertake appropriate action on the basis of additional factors, such as age, family history, coexisting conditions, and (possibly most important) patient preference.Active monitoring as performed in the ProtecT trial should not be used today. We can do better by adding serial multiparametric MRI assessments.9 The increased rate of metastasis that was noted in the active-monitoring group would
likely be diminished with the active surveillance
protocols that are being used today.9This editorial was published on March 11, 2023, at NEJM.org.
1. Hamdy FC, Donovan JL, Lane JA, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate
cancer. N Engl J Med 2023;388:1547-58.
2. Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate
cancer. N Engl J Med 2016;375:1425-37.
3. Sanda MG, Dunn RL, Michalski J, et al. Quality of life and
satisfaction with outcome among prostate-cancer survivors.
N Engl J Med 2008;358:1250-61.
4. American Cancer Society. American Cancer Society recommendations for prostate cancer early detection. February 24,
2023 (https://www.cancer.org/cancer/prostate-cancer/detection
-diagnosis-staging/acs-recommendations.html).
5. Hugosson J, Månsson M, Wallström J, et al. Prostate cancer
screening with PSA and MRI followed by targeted biopsy only.
N Engl J Med 2022;387:2126-37.
6. Jairath NK, Dal Pra A, Vince R Jr, et al. A systematic review
of the evidence for the Decipher genomic classifier in prostate
cancer. Eur Urol 2021;79:374-83.
7. Emmett L, Buteau J, Papa N, et al. The additive diagnostic
value of prostate-specific membrane antigen positron emission
tomography computed tomography to multiparametric magnetic resonance imaging triage in the diagnosis of prostate cancer (PRIMARY): a prospective multicentre study. Eur Urol 2021;
80:682-9.
8. Parker C, Castro E, Fizazi K, et al. Prostate cancer: ESMO
clinical practice guidelines for diagnosis, treatment and followup. Ann Oncol 2020;31:1119-34.
9. Moore CM, King LE, Withington J, et al. Best current practice and research priorities in active surveillance for prostate
cancer — a report of a Movember International Consensus Meeting. Eur Urol Oncol 2023 January 27 (Epub ahead of print).
10. Labbate CV, Klotz L, Morrow M, Cooperberg M, Esserman L,
Eggener SE. Focal therapy for prostate cancer: evolutionary parallels to breast cancer treatment. J Urol 2023;209:49-57.
DOI: 10.1056/NEJMe2300807
Copyright © 2023 Massachusetts Medical Society.
