An expert urologist explains the potential for overtreatment of low-risk prostate cancer and undertreatment of high-risk prostate cancer and the potential consequences for patients.
Stephen J. Freedland, MD: One big issue we have in prostate cancer is matching the aggressiveness of the treatments with the aggressiveness of the tumor. There are 2 places we fall down in doing that. One is we overtreat low-risk disease. That’s a major issue. That was 1 of the main reasons the US Preventive Services Task Force said don’t screen with PSA [prostate-specific antigen] to detect cancer because with urologists and other providers—mainly the blame was with us—the minute they see cancer, they’re going to rush you to the operating room and rip out your prostate and create all these quality-of-life decrements: leaking of urine, problems with erections, risks of surgery in and of itself. You’re not going to live a single day longer or better for having all that done. There’s a lot of truth to that.
As a field, as a community, we’ve learned how to do active surveillance, and there are now data. The majority of men with low-risk disease are going on active surveillance protocols. That’s crucial, and we’ve done a yeoman’s job in terms of that. There’s more work to do. In particular, we need to expand our definition of “low risk.” I use quotes because I’m not talking NCCN [National Comprehensive Cancer Network Guidelines], which are clear in defining low risk. I’m using the term in the concept that this person is at low risk of metastases. We can extend that to at least 7 tumors that have a lethal biology—not all. There are plenty within that group that can be safely observed. That’s the next frontier, and genomic tests and other biomarkers hopefully can get us there.
Likewise, we see patients walk in the door with bad disease, and we’re like, “I don’t want to do too much. Let’s do a bit of surgery and see how it goes. We’ll do your radiation and add some hormones, but we’re not going to do it too long.” The data are still accumulating, but STAMPEDE was telling in terms of adding abiraterone to radiation patients. There are studies ongoing that are testing that and related drugs. For those who are high risk, we need to do super-aggressive local therapies but also combine it with appropriate systemic therapies, aggressive systemic therapies, and combination systemic therapies for a period of time. Not lifetime systemic therapy, but systemic therapy for probably a year. We don’t know. [It could be] more than a couple of months but less than a couple of years. I pick a year.
We do aggressive therapy and then stop and see. Did we create that long-term tumor control? If we did, then we stopped therapy to preserve the quality of life. It’s a constant battle between quality of life and quantity of life. That’s the struggle we face in prostate cancer. At the end of the day, by matching the aggressiveness of the disease with the aggressiveness of the tumor, we can maximize quality and quantity of life.
Transcript edited for clarity.