Matthew R. Cooperberg, MD, MPH
The utilization of active surveillance and prostate-specific antigen (PSA) screening has continued to shift in the recent years, particularly following call-to-actions with the updated recommendations from the US Preventive Services Task Force (USPSTF), ASCO prostate cancer screening guidelines, and the collaborative AUA/ASTRO/SUO guidelines.
“Those guidelines now state that active surveillance is the preferred management strategy for low-risk prostate cancer,” states Matthew R. Cooperberg, MD.
It is now recommended for physicians to have decision-making conversations with their patients regarding the benefits and risks of screening, according to the USPSTF recommendations, a draft of which was released in April 2017. According to Cooperberg, active surveillance rates have increased from 10% to 40% and will continue to increase following these revised recommendations.
In an interview during the 2017 OncLive ®
State of the Science SummitTM on Genitourinary Cancers, Cooperberg, an associate professor of urology and Helen Diller Family Chair in Urology at the University of California, San Francisco (UCSF) School of Medicine, discussed the benefits associated with active surveillance for patients with low-risk prostate cancer, as well as the development of personalized medicine.
OncLive: Can you please provide an overview of your presentation of prostate cancer screening?
It is increasingly clear that prostate cancer screening saves thousands of lives but at the expense of overdiagnosis and overtreatment. There is a growing consensus that screening makes sense but in the context of targeting treatments only for the patients who are going to benefit.
We can risk-stratify prostate cancer consistently based on standard clinical parameters, such as PSA, Gleason score, and their tumor biopsy. Those alone get us to about 80% accuracy and we are then able to refine risk-stratification further with factors such as PSA density, the PSA kinetics, and better assessment of histology. We can do even better with the incorporation of imaging tests, such as MRI, and immersion biomarkers for selected patients.
All of this together gives us the ability to risk-stratify and separate the cancers from those that are likely to progress to a clinically meaningful state from those who are not. We have a consensus including clear guideline statements from ASCO and AUA/ASTRO/SUO, who put out a joint statement at the 2017 AUA Annual Meeting. Those guidelines now state that active surveillance is the preferred management strategy for low-risk prostate cancer. It’s good to have these guidelines, which make it clear that most low-risk prostate cancer should not be treated upfront.
We have recent data suggesting that rates of active surveillance have increased from 10% to 40%, which has been verified in a few different data sources including data from the AUA Quality (AQUA) Registry. Forty percent is still too low, but it is tremendous progress in the right direction.
It was cited by the USPSTF that they have changed the recommendation from “don’t screen anyone” to having a shared decision-making conversation with patients about the risks and benefits of screening. This is what other guidelines are saying, as well.
The role for biomarkers and MRIs is evolving rapidly. There is no adjuvant test that is formally endorsed by the guidelines. Additionally, no adjuvant test—either imaging or biomarker—needs to be used every time for every patient to help make a decision about active surveillance. These tests have a growing role for selective patients, such as those who are particularly anxious about the decision.
There are 3 tissue tests that are on the market: Prolaris®
Prostate Cancer Test, and Oncotype DX®
. All of these can improve our ability to predict the likelihood of the cancer progressing. None of them have been shown to make clear decisions about whether the patient should be treated or not. These tests can help with clinical decision making, but they don’t replace the interpretation of the clinical information and the discussion that the urologist must have with the patient.
MRI is being advocated as a replacement to biopsy and to facilitate decision making but we are not there yet at the community level. This test requires a great deal of some specialty expertise. It has its place and can be useful in select circumstances, but does not need to be used for every patient.