Andrew Stephenson, MD
The paradigm of localized prostate cancer has continued to shift in recent years, especially regarding the utilization of active surveillance and prostate-specific antigen (PSA) screening, according to Andrew Stephenson, MD.
Active surveillance is a resource being increasingly used in clinical practice for patients with low-risk disease, Stephenson said, adding that it should continue to be used as long as it is done appropriately.
Moreover, the use of routine PSA screening is being seen in a different light following evolving recommendations from the US Preventative Services Task Force (USPSTF). In April 2017, the USPSTF released a draft guideline stating that, for men aged 55 to 69, the decision to undergo screening should be on an individualized basis. The USPSTF also said physicians should inform their patients of the risks and benefits associated with screening, and they should decide on the best course of action together.
In an interview during the 2017 OncLive®
State of the Science SummitTM
on Genitourinary Cancers, Stephenson, who is director of Urologic Oncology at Cleveland Clinic, shared some of the past and current data demonstrating the benefits of active surveillance for patients with localized prostate cancer and the evolving opinions on PSA screening.
OncLive: Can you provide an overview of your discussion on active surveillance in prostate cancer?
There has been an important paradigm shift in the management of this disease. We appreciate that there are important impacts on quality of life among the treatments that we would typically offer to patients who have localized prostate cancer—that being surgery and radiation therapy. Although there have been important developments involving the techniques of these treatments, the impact on urinary, bowel, and sexual function continues to be experienced by a substantial number of patients treated with these modalities, even when they are performed by clinicians with substantial expertise.
We also appreciate that the aggressiveness of prostate cancer has changed substantially, in part because of the early diagnostic strategies we have embraced over the last several decades. Stage for stage and grade for grade, the lethality of these cancers that we are currently diagnosing, in some cases, may be somewhat limited. Therefore, by subjecting all patients to treatment for prostate cancer, we may be subjecting them to harm without any real clear benefit.
There have been certain investigators and centers around the country that have embraced active surveillance early on, for which now we have data about the safety and efficacy about this approach. Certainly, it’s clear that for patients who have gone on active surveillance and been followed appropriately, the risk of progression to metastatic disease or prostate cancer mortality is extremely low.
What we have tried to do both here at Cleveland Clinic and at other centers of excellence around the country is to find the appropriate patient for active surveillance. What are the tools we should use to identify candidates for active surveillance? How should these patients be monitored? When should intervention be considered?
Two important developments in this area have been the development of magnetic resonance (MR) and MR-guided biopsy to help identify important cancers and to accurately characterize cancer aggressiveness. Likewise, there has been elegant work looking at genomics and the utility of genomic biomarkers to identify the aggressiveness of prostate cancer to better select patients for treatment.