Updates in the Management of CRPC - Episode 2
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A group of leading prostate cancer experts recently produced a set of consensus statements regarding the best practices for early detection of prostate cancer, at the 2013 Prostate Cancer World Meeting held in Melbourne, Australia. This assay, referred to as the Melbourne Consensus Statement, attempts to clarify the many recommendations presented throughout various guidelines.
The first statement in the report notes that level 1 evidence has demonstrated that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer for men aged 50—69, says David I. Quinn, MD. Moreover, an additional statement suggested that baseline PSA testing for men aged 40–49 effectively predicts the risk of developing prostate cancer in the future. As a result of these statements, Quinn believes the paradigm for screening for prostate cancer is likely to change.
Screening and treatment decisions should to be addressed on an individual basis as part of a shared decision-making process, believes David Albala, MD. This approach applies to all men, whether they are at high-risk or not at risk for developing prostate cancer.
The issue with screening is not the PSA test itself but rather separating a prostate cancer diagnosis from intervention, believes Vahan Kassabian, MD. This need was addressed within the second consensus statement. To accomplish this, patients need to be more effectively selected for treatment, which may require the development of new tools, Kassabian believes.
Looking at a time before PSA testing, approximately 25% of men were diagnosed with metastatic prostate cancer. Following the introduction of testing, that number dropped to 10%, Kassabian states. Based solely on these data, Kassabian believes the number of men diagnosed with advanced disease will greatly increase if PSA is no longer used as a marker during initial testing, warranting its further use.
The need to separate diagnosis from treatment is unquestionable; the difficulty is actually accomplishing this task as part of a shared decision-making process, states E. David Crawford, MD. To address this, patients must be treated smarter, through the development of markers to indicate appropriate patients for active surveillance. On average, Crawford states, less than 8% of patients receive active surveillance when in reality this number should be 30% to 40%.
In general, Crawford feels, PSA should be treated similarly to cholesterol and blood pressure as indicators of an issue that should only be addressed if an abnormality is present. If only patients with abnormal PSA levels above 1.5 ng/ml are considered, the amount of men eligible for treatment drops to around 25%. Due to this believe, Crawford feels that the only way to uncouple diagnosis from treatment is to change how PSA screening is conducted as a whole.