Unresolved Issues in Active Surveillance for Prostate Cancer
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.
However, there are many issues regarding AS eligibility and reporting of pathologic parameters
in biopsies that are unresolved or need further study. Pathologists play a crucial role in sorting these out.
- Inclusion criteria, surveillance schedules, and intervention/progression criteria for men on AS vary between institutions, within institutions, and between clinical trials. Standardization is encouraged.
- Sampling biopsy templates and protocols vary between institutions and trials.
- Studies vary in their approach to determining the extent of cancer when discontinuous foci are present. In addition, prospective studies are needed to determine how best to quantitate discontinuous foci.
- Additional resources and educational material regarding recognition of the cusp in Gleason patterns 3 and 4 are required to decrease interobserver variability.
- Criteria for minimum pattern 4, particularly with respect to poorly formed glands, need to be identified.
- There is need to develop an accurate predictive tool that includes biomarkers in a specifically, prospectively accrued data set to predict outcome of patients on AS.
- Unsampled, high-grade carcinoma remains an important factor in patients failing AS. More-sensitive imaging technologies and biomarkers for high-grade carcinoma, such as in the urine or blood, are required to complement AS eligibility criteria.
- Increased education efforts for urologists, primary care physicians, and pathologists are required to highlight their important respective roles in AS.
Pathologists play an important role on the care team. Criteria need to be reproducible so that reporting is consistent and accurate, demonstrating the crucial role of pathologists in determining eligibility for AS. There needs to be dialogue between pathologists, urologists and other clinicians on the care team.
Ask to see your pathology report. Understand the findings. Make sure the pathology lab is accredited, such as by the College of American Pathologists, and the pathologists are board certified. Ask whether there is a tumor board. A multidisciplinary team approach is the best for patient care. Experience matters.