Guess what? Compared with other tumor cancers like breast cancer or pancreatic cancer, prostate cancer (PCa) has some unique features:

1. It’s the only tumor diagnosed by sticking a large number of needles randomly into an entire small gland (this is basically what a conventional systematic TRUS biopsy is).
2. Autopsies show that over 1/3 of men ages 70-79 died of other causes with PCa that was never diagnosed.^[i] In other words, there’s a lot of PCa out there that never threatens life.
3. Historically, men with PCa have received whole gland treatment regardless of the risk level of their cancer.^[ii]
4. “…most cancers identified through screening efforts are relatively indolent, posing minimal threat to length or quality of life for years or decades after diagnosis.”^[iii]

Nearly 20 years ago, the World Journal of Urology published a Dutch paper on early detection of prostate cancer (PCa) with its potential for unfortunate consequences. In my experience, I haven’t met a single person who would quibble with the notion that cancer should be found at the earliest possible stage. And yet, the Dutch authors wrote, “Early detection of prostate cancer is associated with the diagnosis of a considerable proportion of cancers that are indolent, and that will hardly ever become symptomatic during lifetime.”^[iv] Indolent literally means lazy or inactive. The Prostate Cancer Foundation likens it to a very slow-moving animal, like a turtle or a sloth—or not moving at all: “Indolent prostate cancer is the pet rock of cancers; it doesn’t do much, but the upside of that is that it doesn’t need to be treated, either.”

But, as stated in point number 3 above, the history of PCa is littered with patients who were aggressively treated by removing the entire gland, or radiating it. In turn, this has left untold thousands of men with urinary leakage, limp penises, or bowel problems—not to mention the depression and anxiety that accompany long-term pelvic problems.

I’m writing this near the end of 2024, a full 17 years since the Dutch article appeared in 2007. Even back then, the authors were calling for an end to overdiagnosis “in all forms” because it leads to overtreatment of indolent disease. The solution is not to cut back on screening, but rather beef up PSA screening so we know right from the start who needs a biopsy and who doesn’t. More importantly, we identify who needs whole-gland treatment, and who doesn’t. In fact, thanks to progress in the PCa world, overdiagnosis is well on its way out.

Helpful developments

Two developments in particular have emerged as PSA game-changers. First, we know that the non specific PSA test has been at the heart of a rushed diagnostic pathway that resulted in immediate TRUS biopsy after an abnormal PSA result. This method led to higher than 30% inaccuracy rates (overdetection of indolent disease, underdetection of significant PCa). Thankfully, it is now recommended to insert some intervening steps before rushing to biopsy:

• Repeat the PSA test within several weeks
• If it’s still high, have a multiparametric MRI scan
• If the scan reveals a suspicious area, have an MRI-guided targeted scan (preferably in-bore) to precisely sample the area with a minimal number of needles.
• If the needle biopsy is positive, and there are other known risk factors (family history of cancer, exposure to toxic substance, ethnic/racial lineage, etc.) have a genomic analysis to rule out dangerous mutations prior to a treatment decision.

Adding these steps actually saves medical dollars in the long run, but that’s for another blog.

Regarding the second development, if indolent prostate cancer is diagnosed, there are two main ways to manage the disease while avoiding overtreatment:

• Active Surveillance (AS) is increasingly recommended to patients, not only because it holds off on treatments, but also because many men on AS embrace lifestyle changes in their diet, exercise and stress management that have been shown to have preventive value against cancer worsening.
• Focal therapy, which offers selective tumor destruction (cancer control) with very little risk of side effects. This brings peace of mind, and AS can still be used to monitor the healthy gland tissue which is not affected by focal therapy.

The benefits of choosing focal therapy are 1) in many cases, it completely eliminates a truly focal tumor so it ends the threat of cancer coming back, 2) it preserves urinary and sexual function, and 3) it leaves all future treatment options open.

Thus, both AS and focal therapy are ways to hold off on overtreatment, in some cases for life. As a reminder, the Sperling Prostate Cancer offers Focal Laser Ablation, TULSA, and Exablate MR-guided Focused Ultrasound. We are doing our part to put an end to overtreatment, and we have a long track record of doing so! If you want to join the movement to end overtreatment, contact us to learn how we can be of assistance.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Jahn JL, Giovannucci EL, Stampfer MJ. The high prevalence of undiagnosed prostate cancer at autopsy: implications for epidemiology and treatment of prostate cancer in the Prostate-specific Antigen-era. Int J Cancer. 2015 Dec 15;137(12):2795-802.
[ii] Cooperberg MR, Meeks W, Fang R et al. Time Trends and Variation in the Use of Active Surveillance for Management of Low-risk Prostate Cancer in the US. JAMA Netw Open. 2023 Mar 1;6(3):e231439.
[iii] Ibid.
[iv] Bangma CH, Roemeling S, Schröder FH. Overdiagnosis and overtreatment of early detected prostate cancer. World J Urol. 2007 Mar;25(1):3-9.