Divorcing Diagnosis From Treatment: Contemporary Management of Low-Risk Prostate Cancer

Abstract

Today, the majority of men with newly diagnosed prostate cancer will present with low-risk features of the disease. Because prostate cancer often takes an insidious course, it is debated whether the majority of these men require radical treatment and the accompanying derangement of quality of life domains imposed by surgery, radiation, and hormonal therapy. Investigators have identified various selection criteria for "insignificant disease," or that which can be monitored for disease progression while safely delaying radical treatment. In addition to the ideal definition of low risk, a lack of randomized trials comparing the various options for treatment in this group of men poses a great challenge for urologists. Early outcomes from active surveillance cohorts support its use in carefully selected men with low-risk disease features, but frequent monitoring is required. Patient selection and disease monitoring methods will require refinement that will likely be accomplished through the increased use of biomarkers and specialized imaging techniques.

Clonal evaluation of prostate cancer foci in biopsies with discontinuous tumor involvement by dual ERG/SPINK1 immunohistochemistry

“…Although prostate cancer is the second leading cause of cancer-related deaths in men in the US, early detection with serum prostate-specific antigen (PSA) has led to the over-detection and over-treatment of indolent prostate cancer( 1 – 3 ). Recently, active surveillance, where men newly diagnosed with prostate cancer undergo serial biopsy, PSA and/or imaging to delay intervention until prompted by clinicopathological evidence of disease progression (or patient decision), has emerged as management strategy for low risk prostate cancer that does not significantly decrease prostate cancer specific mortality compared to immediate treatment( 4 – 6 ).…”

“…Despite advances in imaging and prognostic expression/protein assays, serum PSA and clinicopathological parameters are the only factors routinely used to assess prognosis at diagnosis ( 4 , 6 – 11 ). Although pathological inclusion criteria for active surveillance protocols vary by institution or group, almost all include Gleason score, number (or percentage) of positive cores and the tumor measurement/length or maximum percentage of tumor involvement in any core ( 4 , 5 , 11 – 15 ).…”