Interesting discussion on a topic about which I know nothing. But I’m an interested observer, being the proud owner of a prostate.
It seems even the upstream questions of who should get a PSA, and when, are still not conclusively answered.
And it also seems the Gleason scale may leave something to be desired in terms of identifying the cancers a pt would care most about (eventually fatal, not yet metastasized).
This study reinforces early observational studies from the ultrasound guided biopsy era: that treatment at progression is non-inferior to immediate treatment and that about 1/3 of patients initially placed on observation will progress.
The study is a snapshot of a bygone era. With MRI guided biopsy and genomics far fewer patients are upgraded or upstaged at surveillance follow up. Our impression is that anterior and transition zone cancers were frequently missed by ultrasound guided biopsy. This alone likely explains the frequent upstaging noted by the authors. Genomics (we use Decioher, but likely all the test systems are similar) show that 1/3 of high volume low grade cancers have genomic characteristics of more aggressive cancers and that about 1/4 of low volume intermediate grade cancers can safely be observed.
Taken together, using MRI guided biopsy and genomics, we place about 1/3 of patients on surveillance and convert about 1/10 of patients to treatment over the first four years.
I am waiting for follow-on trials to show whether I can safely withhold further biopsy after the first four years. As a practical matter, most patients past age 70 decline repeat biopsy unless you can show them MRI or PSA evidence of progression.
And stress, anxiety and the like. Of course it's not about the individual it's about what the docs and "do to you" to "help" you.
"Not considered in these studies are the indirect costs related to missed workdays, adverse events, and other inconveniences attributed to the routine follow-up required."
False Positives and Harms
About 75% of positive PSA tests are false positives, which can lead to psychological harm and unnecessary diagnostic testing and treatment. This can result in complications such as erectile dysfunction, urinary incontinence, bowel dysfunction, and even death.
Current algorithms incorporating findings from the PROTECT and PRECISION trials especially have supported a more conservative and tailored approach to prostate cancer management, focusing on maintaining quality of life while ensuring effective monitoring and timely treatment of significant disease.
That’s an interesting question. You’ll typically find PSA kinetics (velocity, doubling time) in surveillance but not PSAD, and I suspect it is for a number of reasons (a main one being the feasibility of pairing an accurate volume with PSA - remember, most patients are screened and followed by their primary doctors). Also, there are some issues with the inflexible cutoff values (per my understanding) that complicate clinical decision making.
Congrats!
We need more of this curious and critical appraisal doctors than the usual KOLs and acritical guideline-chasers.
Nice job, med students.
PSAs are make-work projects for Urologists, and make-miserable projects for patients.
Will someone please let Michael Milken in on this fact?
Interesting discussion on a topic about which I know nothing. But I’m an interested observer, being the proud owner of a prostate.
It seems even the upstream questions of who should get a PSA, and when, are still not conclusively answered.
And it also seems the Gleason scale may leave something to be desired in terms of identifying the cancers a pt would care most about (eventually fatal, not yet metastasized).
This study reinforces early observational studies from the ultrasound guided biopsy era: that treatment at progression is non-inferior to immediate treatment and that about 1/3 of patients initially placed on observation will progress.
The study is a snapshot of a bygone era. With MRI guided biopsy and genomics far fewer patients are upgraded or upstaged at surveillance follow up. Our impression is that anterior and transition zone cancers were frequently missed by ultrasound guided biopsy. This alone likely explains the frequent upstaging noted by the authors. Genomics (we use Decioher, but likely all the test systems are similar) show that 1/3 of high volume low grade cancers have genomic characteristics of more aggressive cancers and that about 1/4 of low volume intermediate grade cancers can safely be observed.
Taken together, using MRI guided biopsy and genomics, we place about 1/3 of patients on surveillance and convert about 1/10 of patients to treatment over the first four years.
I am waiting for follow-on trials to show whether I can safely withhold further biopsy after the first four years. As a practical matter, most patients past age 70 decline repeat biopsy unless you can show them MRI or PSA evidence of progression.
And stress, anxiety and the like. Of course it's not about the individual it's about what the docs and "do to you" to "help" you.
"Not considered in these studies are the indirect costs related to missed workdays, adverse events, and other inconveniences attributed to the routine follow-up required."
False Positives and Harms
About 75% of positive PSA tests are false positives, which can lead to psychological harm and unnecessary diagnostic testing and treatment. This can result in complications such as erectile dysfunction, urinary incontinence, bowel dysfunction, and even death.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183963/
Great, thoughtful post.
Current algorithms incorporating findings from the PROTECT and PRECISION trials especially have supported a more conservative and tailored approach to prostate cancer management, focusing on maintaining quality of life while ensuring effective monitoring and timely treatment of significant disease.
Should there be more use of PSAD in the protocol?
That’s an interesting question. You’ll typically find PSA kinetics (velocity, doubling time) in surveillance but not PSAD, and I suspect it is for a number of reasons (a main one being the feasibility of pairing an accurate volume with PSA - remember, most patients are screened and followed by their primary doctors). Also, there are some issues with the inflexible cutoff values (per my understanding) that complicate clinical decision making.