Originally published 8/14/2014
This update begins with a quote from urologist Dr. Stephen Freedland (Cedars-Sinai Medical Center, Los Angeles) who places most of the blame for over-treating low risk prostate cancer (PCa) on his urologic comrades:
“…the minute they see cancer, they’re going to rush you to the operating room and rip out your prostate and create all these quality-of-life decrements: leaking of urine, problems with erections, risks of surgery in and of itself. You’re not going to live a single day longer or better for having all that done.”
In the 9 years between the August 14, 2014 blog below and Dr. Freedland’s July 29, 2022 video comments, the problem of overtreatment has become widely recognized.
In August, 2022 a multinational team published an overview of the decade-long progress in PCa detection, diagnosis and treatments thanks to MRI: “Early detection and management of prostate cancer has evolved over the past decade, with a focus now on harm minimisation and reducing overdiagnosis and overtreatment, given the proven improvements in survival…”[i]
With greatly improved ability to match an individual’s cancer with treatment tailored to his disease, overtreatment is thankfully falling by the wayside. However, most urologists offer low-risk patients only Active Surveillance as an alternative to radical surgery or radiation.
Unfortunately, many urologists still see focal therapy as an emerging experimental treatment modality[ii] and aren’t likely to suggest focal treatment unless they themselves offer it using an ultrasound-guided method like HIFU. W
hile we are happily able to update the original blog with the good news that overtreatment is much less rampant, it’s important to point out that MRI guided focal treatments like our own Focal Laser Ablation, MRI guided Focused Ultrasound (Exablate) and MRI guided TULSA use superior imaging for treatment planning, accurate delivery, and precision real-time confirmation of treatment effect.
If the name of Dr. Otis Brawley is not as familiar as Dr. Salk or Dr. Spock, it doesn’t surprise me. It’s not exactly a household word. However, Dr. Brawley holds an important position as the chief medical officer of the American Cancer Society. As a practicing oncologist (specialist in treating cancer) he considered a world cancer expert, and he is the author of “How We Do Harm: A Doctor Breaks Ranks About Being Sick In America.” So when Dr. Brawley speaks out, he’s worth listening to. This week, CNN gave him a platform to comment on how prostate cancer is overtreated. He issued a forceful statement that this needs to be stopped.
Dr. Brawley referred to two recent studies in the Journal of the American Medical Association (JAMA) that reveal the extent to which prostate cancer is subjected to heavy-handed treatment methods. One study examined how many men are initially put on testosterone reducing drugs—in effect, chemical castration. There is no solid evidence that the use of these medications gives a survival advantage.
The second study was of greater interest to me. It explored the common practice of treating men with early stage, low risk disease by either prostatectomy or radiation. In many cases, these patients could have gone on active surveillance as a way to delay treatments that potentially leave men with urinary, sexual and bowel dysfunction. More importantly—and this is where I truly believe our Center is doing patients a great service—I have to wonder how many of such cases would be perfect candidates for an MRI-guided focal laser ablation? As we know, early stage disease often consists of a single small focus of clinically significant cancer that can readily be destroyed without risk of side effects. Future monitoring can be done by multiparametric MRI, and no treatment windows have been closed should cancer recur.
Dr. Brawley himself points out that many prostate cancers will never progress. If they are carefully monitored, countless patients may never move to the stage where treatment is necessary. As our center and many others around the country offer advanced imaging, I want to point out that even biopsies can be avoided unless imaging reveals a suspicious area.
I’m glad that Dr. Brawley was able to broadcast his message, and I’m proud that the Sperling Prostate Center falls under its banner.
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] Williams IS, McVey A, Perera S, O’Brien JS et al. Modern paradigms for prostate cancer detection and management. Med J Aust. 2022 Oct 17;217(8):424-433.
[ii] Ibid.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
