The US preventive services task force (USPSTF) recently changed their recommendation on prostate cancer screening from discouraging men from being screened at all ages to recommending men aged 55-69 discuss the benefits and harms of PSA testing with their doctor and make an informed decision. Why? The answer lies in changes in how we diagnose prostate cancer and how low grade prostate cancer is managed. Early detection of prostate cancer in men aged 55-69 is likely to lead to a reduction in the incidence of metastatic disease in these men and prostate cancer mortality.
Prostate cancer accounts for over 20,000 cancer diagnoses and over 3000 deaths annually in Australia. However, most men diagnosed with prostate cancer will not die of the disease because in many cases it is a slowly progressive disease.
The treatment for prostate cancer, in particular advanced prostate cancer has changed over the last few years. There are now many options to slow the progression of incurable metastatic prostate cancer – all come at a cost however, both side effects to the patient and financial cost to the health system (expensive new drugs taken over many years).
Definitive treatment and cure of prostate cancer may decrease the financial burden of metastatic disease.
Changes in diagnostic methods
One of the main criticisms of PSA screening was that it resulted in too many men being referred for unnecessary prostate biopsies. These were most commonly done transrectally with core needle biopsy and whilst generally safe, a sepsis rate of around 2% was reported. Steps to decrease the sepsis rate include the use of fluoroquinolones, preparing the rectum with betadine and identifying men at risk of harbouring multi-resistant bacteria (usually recent travel to south-east Asia).
Two of the biggest advances in more accurate and safer diagnosis were the use of multiparametric prostate MRI and transperineal prostate biopsy.
MRI has led to a decrease in prostate biopsies because of improved accuracy in determining who needs one and where the biopsy should be targeted. While it is not 100% accurate and must be interpreted in the context of PSA levels and clinical findings, most urologists agree MRI has improved both the accuracy of diagnosis and treatment planning.
Transperineal prostate biopsy uses a grid template to take more biopsies of the prostate and is able to accurately target areas of abnormality seen on MRI. Because the needle passes through the skin there is a very low risk of infection – some large volume centres report a zero sepsis rate (compared with transrectal biopsy, transperineal biopsy requires a GA and takes longer).
Active surveillance vs active treatment
For men with low volume and low grade (Gleason score 6) cancer and low PSA, active surveillance with regular PSA check, prostate examination and re-biopsy has been proven to have an excellent rate of safety over many years. Patients who show evidence of stage or grade progression are switched to active therapy. This is very reassuring to patients – the knowledge that low grade disease can be safely watched.
The side effect profiles of active treatment for clinically localised disease for both surgery and radiotherapy are continuing to improve. Robotic surgery allows faster recovery and less blood loss. Radiation is continuing to evolve with dose fractionation and image guided therapy.
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