A discussion surrounding the changing landscape of early-stage prostate cancer screening and rise in metastatic disease cases, focusing on the importance of timely intervention and patient-focused care.
David Morris, MD, FACS: We’d like to move on now and talk a little about screening for an early-stage diagnosis of prostate cancer. I think it’s important that we don’t lose sight of the forest for the trees, that most men with prostate cancer, thankfully, will not be faced with many of the things we’re talking about. We’re talking 90% of men will have localized disease, which is well managed. It’s typically caught early with PSA [prostate-specific antigen] screening, surveillance with primary care physicians, early referral to urologists for things [such as] biopsies, and now even more commonly MRI evaluation of the prostate, fusion biopsies, transperineal biopsies. There’s a whole host of technologies that have really improved our early-stage screening and appropriate staging. So 90% of men hopefully never get to the point where they need to meet a medical oncologist.
They may be cured by me as a urologist. They may be cured by a radiation oncologist who is also part of this discussion for a multidisciplinary approach. But with some shifts in screening in the past few years, the decline of this PSA testing unfortunately has led to an increase in our men [receiving diagnoses of] metastatic disease at presentation. And whether that’s access to care in certain communities, certain populations don’t typically have a lot of screening going on in their communities, but it’s not uncommon now for us from our partnership to see 1 or 2 patients a week with metastatic disease at the time of presentation and diagnosis.
That de novo disease has certainly been on the rise in our clinics, part of it probably from PSA, part of it due to aging populations where we have healthy men in their 80s who are at risk, and they may live long enough to have metastatic disease after we stop PSA screening. That onus is on us to recognize those are the men we need to focus our attention on because those are the ones who are at risk for having progression.
And secondary to that group are the men whom we think we’ve cured who have a recurrence of disease [and] who are started on hormone therapy for that recurrence. Unfortunately, [they] can progress, often now, to castration-resistant prostate cancer [CRPC], whether it’s metastatic or nonmetastatic. The advent of new PSA imaging techniques and conventional bone scan and CT have really muddied the water in terms of how we risk stratify those men with CRPC disease, but they have a whole host of options available, and it’s important that they either see [a] urologist who focuses a lot on this or get sent from a urologist who recognizes the disease transition to a medical oncologist who can then take over and drive that care if the urologist is not interested in doing that.
Ben, I like your medical oncology snapshot of what it is like for early-stage diagnosis. Are you seeing this rise in metastatic de novo disease, and how early do you want to get involved for these men with prostate cancer?
Benjamin Garmezy, MD: There has been a shift toward more metastatic disease. I read a paper not too long ago that suggested historically about somewhere between 4% and 5% of patients with prostate cancer and metastatic disease may be increasing to 7% to 8%. Although [those sound] like small numbers, that’s a huge shift when you think about the population at large in this country. And the other debate that’s in the medical oncology world is if we overscreen, we’re going to find all these small cancers. Everyone watching this probably understands that it’s a Gleason 6 [score] cancer. Should we even call that cancer?
And that probably in some ways does some harm in the sense that instead of focusing on nomenclature and how we view whether these cancers need [management], we know that if we detect the cancers, we can surveil them appropriately. Not every cancer needs [management], and perhaps shifting our education not toward not doing diagnostic screening so that we’re afraid of our interventions but rather doing the screening and then appropriately being able to identify who has a lethal disease and who has a nominal disease.
Transcript is AI generated and edited for readability.