Advances in Urology: Focus on Prostate Cancer
As I reflect on advances in the practice of urology over the past year, the approval of several new therapies for prostate cancer immediately comes to mind. Perhaps even more important was an improved understanding of how to manage several stages of the disease. Principal among these changes is a major paradigm shift across the world with respect to the management of low-risk prostate cancer.
Clinicians increasingly are recognizing that many of the men diagnosed by a screening test of their prostate-specific antigen (PSA) level have a very low likelihood of developing progressive disease. For that reason, immediate local therapy in most cases appears to offer patients little benefit while subjecting them to the side effects of various therapies. Unfortunately, the use of external radiation is increasing, possibly a consequence of the financial incentives available to urologists who purchase their own radiation equipment, or because some radiation centers are now offering proton beam radiation under the promise of fewer side effects despite the absence of any data to support those claims.
Active surveillance with careful monitoring, followed by local therapy if the disease progresses, is emerging as a very appropriate option for many low-risk men (PSA < 10 ng/mL, T1c, T2a, Gleason score 3+3). Although no randomized study has yet been reported, outcomes data are accumulating from case series that can be used to discuss active surveillance with patients.
Much more information is needed, however, about how to select, counsel, and monitor these men and about the indications for discontinuing the surveillance approach. For now, however, more men clearly need to be informed that active surveillance is a reasonable option for managing their disease.
Paradigm Shift in Localized Prostate Cancer
As I reflect on advances in the practice of urology over the past year, the approval of several new therapies for prostate cancer immediately comes to mind. Perhaps even more important was an improved understanding of how to manage several stages of the disease. Principal among these changes is a major paradigm shift across the world with respect to the management of low-risk prostate cancer.
Clinicians increasingly are recognizing that many of the men diagnosed by a screening test of their prostate-specific antigen (PSA) level have a very low likelihood of developing progressive disease. For that reason, immediate local therapy in most cases appears to offer patients little benefit while subjecting them to the side effects of various therapies. Unfortunately, the use of external radiation is increasing, possibly a consequence of the financial incentives available to urologists who purchase their own radiation equipment, or because some radiation centers are now offering proton beam radiation under the promise of fewer side effects despite the absence of any data to support those claims.
Active surveillance with careful monitoring, followed by local therapy if the disease progresses, is emerging as a very appropriate option for many low-risk men (PSA < 10 ng/mL, T1c, T2a, Gleason score 3+3). Although no randomized study has yet been reported, outcomes data are accumulating from case series that can be used to discuss active surveillance with patients.
Much more information is needed, however, about how to select, counsel, and monitor these men and about the indications for discontinuing the surveillance approach. For now, however, more men clearly need to be informed that active surveillance is a reasonable option for managing their disease.
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