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March 2, 2016
More than 200,000 men will develop prostate cancer this year, making it the #1 cancer after skin cancer. Almost 30,000 men will die of prostate cancer, second only to lung cancer. There is much controversy surrounding the PSA test. One of our best markers for detecting prostate cancer has been the PSA test. However, critics point to the risks of overdiagnosis and overtreatment of indolent cancers that would otherwise not have impacted the patient. As such active surveillance (AS) has become an option in select patients.
What is active surveillance?
AS is a reserved for patients with low grade, low volume cancer. Specific criteria often vary but usually include age, PSA density (PSA/prostate volume), percentage of positive biopsy cores, the extent of prostate cancer in any core, and measures of PSA kinetics, such as PSA velocity. Patents undergo regular visits, PSA testing and repeat biopsies instead of upfront aggressive treatment. It is different than “watchful waiting” which is typically offered to older patients with significant comorbidities where life expectancy is not expected to be impacted by treatment.
Intervention will occur if there is evidence of tumor progression. This can include PSA change, changes in clinical staging or imaging, and findings on repeat biopsy that are indicative of a larger or higher-grade cancer, i.e. increased Gleason score or increased volume of tumor in the core biopsies.
Pathologists play a key role in the treatment of prostate cancer patients. All treatment begins with a diagnosis. Each patient’s journey begins with the pathologist’s diagnosis.
Canadian study proves effectiveness of active surveillance
A new study out of The Ottawa Hospital and the University of Ottawa shows that men with slow growing, indolent tumors are opting for AS. Researchers found patients undergoing AS increased from 32 percent in 2008 to 68 percent in 2013. The accurate and precise diagnosis of the pathologist allows for the effectiveness of AS.
What is precision medicine?
Precision medicine has transformed the approach to treating cancer. In contrast to conventional chemotherapy which involves toxic drugs which kill both cancerous and normal cells, causing many side effects, precision medicine selectively targets a patient’s unique tumor characteristics.
Pathologists are involved in each step of the process. First, a tumor may be biopsied in either the operating room or radiology under CAT scan guidance. Pathologists are called upon to assess the sample, ensuring it is adequate for both diagnosis and testing for precision medicine targets (“actionable mutations”).
In the lab, pathologists examine tissues under the microscope using various stains to make a diagnosis. When appropriate, a tumor is tested for the presence of “actionable mutations”. If discovered, the patient may be eligible for targeted therapy. The success of precision medicine depends on pathologists.
Single biopsy could provide enough molecular information
In a new study researchers showed that though metastases from different patients varied widely in their genetic characteristics, metastases within a single patient were remarkably similar. These results suggest not merely that patients with metastatic prostate cancer may benefit from treatment tailored to their particular tumors, but also that a single biopsy may provide enough information to oncologists to guide such therapy.
Both of these new studies demonstrate that pathologists are crucial members in the care of prostate cancer patients.
What can you do?
Talk with your physician about factors that impact your level of risk for prostate cancer and your need for early, regular PSA testing. Risk factors include:
Family history: Depending on whether you have a family history of cancer, you may not need to be screened immediately, but if you’re an average man over 40, it’s time to begin a conversation with your doctor about prostate cancer screening.
Your general health: For example, obesity may not increase your risk, but it can make prostate cancer harder to detect through PSA testing.
Race: Clinical studies find that PSA levels and tumor loads vary distinctly between black and white prostate cancer patients.
Your physician should also explain what the test might show and help you prepare to consider options if PSA levels are elevated. Ask about the pathologist behind your care. The best treatment is that of a multidisciplinary team approach. Through shared decision making with your doctor, and in particular, understanding your pathology report, you will be assured of the best care.