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Who to Screen: Finding the High-Risk Prostate Cancer Patient

Insights From: E. David Crawford, MD, University of Colorado in Denver; Matthew T. Rosenberg, MD, Allegiance Health Systems; Daniel Petrylak, MD, Yale School of Medicine
Published: Wednesday, Dec 07, 2016



Transcript:

E. David Crawford, MD:
Hello, and thank you for joining us for this discussion on “Improving Prostate Cancer Outcomes, A Model for Shared Care.” In the past several years, we’ve seen a substantial reduction in the number of men being screened for prostate cancer, leading to an overall decline in new cases. However, new data suggest that the incidence of metastatic disease has risen dramatically, with PSA (prostate-specific antigen) values at diagnosis also rising. Moreover, the number of prostate cancer survivors continue to increase. Important goals include decreasing the risk of overtreating men with low-risk disease, earlier diagnosis of aggressive tumors, and individualized long-term survivorship plans. In this OncLive Insights®, we’ll be discussing the concept of a shared-care model involving urologists, oncologists, and primary care to optimize long-term outcomes for men living with prostate cancer.

I am E. David Crawford, and I am a professor of surgery/urology/radiation oncology and head of Urologic Oncology at the University of Colorado in Denver, Colorado. Participating today are, to my right, Dr. Daniel Petrylak, director of the Genitourinary Oncology Research Program and co-director of the Signal Transduction Program at the Yale Comprehensive Cancer Center of the Yale School of Medicine in New Haven, Connecticut. And to my left is Dr. Matt Rosenberg, medical director of MidMichigan Health Centers in the Department of Family Medicine at the Allegiance Health Systems in Jackson, Michigan. Thank you so much for joining us.

Let’s begin. Let’s begin our discussion about some of the challenges in prostate cancer, and really there are several. The one that’s in the limelight right now is this overdiagnosis of prostate cancer, and also now the controversy is finding more patients with more aggressive disease. So, this all stems from what the US Preventive Services Task Force is giving a D rating. Matt, tell us what your thoughts are about the family practice arena dealing with these men with prostate cancer and this whole controversy about should you screen, and on overdiagnosis and overtreatment.

Matthew T. Rosenberg, MD: It’s interesting. If you look at the data, about 90% of all PSAs are done by primary care. So, just as you said, we are the gatekeepers to this. And where we get our guidance is from the United States Preventive Service Task Force, as well as our own academies. Unfortunately, they’re all in line saying, “Don’t screen.” Now, I don’t agree with that. I don’t agree with what the US Preventive Services Task Force said because they made a reaction to the PSA. So, if we just look at the PSA, which is a nonspecific way to look for prostate cancer, then we’re missing an opportunity—and we’re missing an opportunity to find the right patient. And the reality is we can utilize the PSA in a correct fashion. If we look at the risk of prostate cancer as it pertains to the PSA, there is a risk that goes up. We use the number 1.5 ng/dL. You and I have discussed it many times. After that PSA gets to 1.5, then we need a better evaluation for that. So, if we rely just on the PSA, it’s nonspecific, but if we start to be intelligent about this and use the data that we’ve had recently—for example, the biomarkers—we can address this. We can find the right patient because that’s the trick here. It’s finding the right patient who’s at risk of that life-threatening, aggressive prostate cancer. If we could find them, then we’re going to stop the risk that some patients will have of developing metastatic disease.

E. David Crawford, MD: Let me just summarize. First of all, you said—and I think a lot of people don’t know this—the bulk of PSAs in the United States, 90%, are ordered by family practice, internal medicine doctors.

Matthew T. Rosenberg, MD: Yes.

E. David Crawford, MD: Secondly, you believe that there is a way forward that we shouldn’t just stop screening.

Transcript Edited for Clarity
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Transcript:

E. David Crawford, MD:
Hello, and thank you for joining us for this discussion on “Improving Prostate Cancer Outcomes, A Model for Shared Care.” In the past several years, we’ve seen a substantial reduction in the number of men being screened for prostate cancer, leading to an overall decline in new cases. However, new data suggest that the incidence of metastatic disease has risen dramatically, with PSA (prostate-specific antigen) values at diagnosis also rising. Moreover, the number of prostate cancer survivors continue to increase. Important goals include decreasing the risk of overtreating men with low-risk disease, earlier diagnosis of aggressive tumors, and individualized long-term survivorship plans. In this OncLive Insights®, we’ll be discussing the concept of a shared-care model involving urologists, oncologists, and primary care to optimize long-term outcomes for men living with prostate cancer.

I am E. David Crawford, and I am a professor of surgery/urology/radiation oncology and head of Urologic Oncology at the University of Colorado in Denver, Colorado. Participating today are, to my right, Dr. Daniel Petrylak, director of the Genitourinary Oncology Research Program and co-director of the Signal Transduction Program at the Yale Comprehensive Cancer Center of the Yale School of Medicine in New Haven, Connecticut. And to my left is Dr. Matt Rosenberg, medical director of MidMichigan Health Centers in the Department of Family Medicine at the Allegiance Health Systems in Jackson, Michigan. Thank you so much for joining us.

Let’s begin. Let’s begin our discussion about some of the challenges in prostate cancer, and really there are several. The one that’s in the limelight right now is this overdiagnosis of prostate cancer, and also now the controversy is finding more patients with more aggressive disease. So, this all stems from what the US Preventive Services Task Force is giving a D rating. Matt, tell us what your thoughts are about the family practice arena dealing with these men with prostate cancer and this whole controversy about should you screen, and on overdiagnosis and overtreatment.

Matthew T. Rosenberg, MD: It’s interesting. If you look at the data, about 90% of all PSAs are done by primary care. So, just as you said, we are the gatekeepers to this. And where we get our guidance is from the United States Preventive Service Task Force, as well as our own academies. Unfortunately, they’re all in line saying, “Don’t screen.” Now, I don’t agree with that. I don’t agree with what the US Preventive Services Task Force said because they made a reaction to the PSA. So, if we just look at the PSA, which is a nonspecific way to look for prostate cancer, then we’re missing an opportunity—and we’re missing an opportunity to find the right patient. And the reality is we can utilize the PSA in a correct fashion. If we look at the risk of prostate cancer as it pertains to the PSA, there is a risk that goes up. We use the number 1.5 ng/dL. You and I have discussed it many times. After that PSA gets to 1.5, then we need a better evaluation for that. So, if we rely just on the PSA, it’s nonspecific, but if we start to be intelligent about this and use the data that we’ve had recently—for example, the biomarkers—we can address this. We can find the right patient because that’s the trick here. It’s finding the right patient who’s at risk of that life-threatening, aggressive prostate cancer. If we could find them, then we’re going to stop the risk that some patients will have of developing metastatic disease.

E. David Crawford, MD: Let me just summarize. First of all, you said—and I think a lot of people don’t know this—the bulk of PSAs in the United States, 90%, are ordered by family practice, internal medicine doctors.

Matthew T. Rosenberg, MD: Yes.

E. David Crawford, MD: Secondly, you believe that there is a way forward that we shouldn’t just stop screening.

Transcript Edited for Clarity
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