Prostate cancer: to treat or not to treat, a cautionary tale from a doctor-patient

Vollständiger Abstract

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Background: A definitive diagnosis of prostate cancer can be established with a special type of MRI (multiparametric MRI) followed by core biopsy. An assessment of stage (extent of spread) and grade (aggressiveness of disease) from these investigations assists with clinical decision-making regarding early management. Objective: This article describes the evidence supporting active surveillance for low-risk prostate cancer and the limitations of diagnostic tools in choosing between active surveillance and surgery (radical prostatectomy) for newly diagnosed prostate cancer. It addresses an important aspect of patient safety and aims to inform physicians and (through them) patients. The article also discusses the potential adverse outcomes of radical prostatectomy and issues relating to biochemical recurrence after surgery. Radiation therapy lies outside the scope of this article. Discussion: mpMRI / core biopsy can significantly underestimate the stage and grade of prostate cancer, and there is a risk that the disease could be a higher stage and/or grade than is appropriate for active surveillance. A real-life clinical vignette illustrates that prostate cancer initially diagnosed as stage T2 / grade group 1 (low risk) quickly proved (post-surgically) to be stage T3 / grade group 2 (high risk). The former would have been a candidate for active surveillance; the latter would not. When appropriate, prostatectomy should not be avoided because of fear of adverse effects. The definition and clinical relevance of biochemical recurrence continue to be debated. Keywords: prostate cancer · active surveillance · diagnosis · prostatectomy