“The use of multi-parametric magnetic resonance imaging (mpMRI) could help avoid a repeat prostate biopsy in some men, according to a new study. The imaging test has a high sensitivity for clinically significant cancers, but could miss some and overdiagnose insignificant cancers as well.
” ‘The prostate cancer diagnostic pathway is very different to that of almost all other solid organ cancers, in that it is calibrated to detect subclinical disease but often misses clinically important disease,’ wrote study authors led by Lucy A. M. Simmons, MBBS, MRCS, of University College London. That imprecision arises from the use of transrectal ultrasound-guided (TRUS) biopsy, which is considered standard in men with elevated prostate-specific antigen (PSA) levels.”
“Giving men with suspected prostate cancer an MRI scan could improve diagnosis and save those who do not have aggressive cancers from having an unnecessary biopsy, according to a study published in The Lancet.
“The study estimates that adding the extra test could help one in four (27%) men avoid an unnecessary biopsy and reduce the number of men who are over-diagnosed – diagnosed with a cancer that does not go on to cause any harm during their lifetime – by 5%.”
“Recent studies have reopened discussion of a seemingly closed case against earlier use of chemotherapy in prostate cancer.
“Chemotherapy has an established role in the management of metastatic castration-resistant prostate cancer, but its use in earlier-stage disease has remained controversial. Given the heterogeneous nature of the disease, prolonged clinical course associated with indolent disease, and concern about overdiagnosis and overtreatment, clinicians have reached no consensus about potential patient subgroups that might benefit from earlier use of chemotherapy. Differences of opinion played out again in pro/con articles published online in JAMA Oncology.”
“A paper published in the Journal of Clinical Oncology, authored by Tosoian et al, reports on the long-term outcomes of prospective active surveillance (AS) of patients with favorable-risk prostate cancer.
“The authors point out that the common widespread practice of screening for prostate cancer in the United States, using prostate-specific antigen (PSA), may have led to overdiagnosis and overtreatment of the disease.
“The US Preventive Services Task Force has issued a grade D recommendation to reduce the use of PSA screening, and the National Institutes of Health has made a study of the outcomes of AS a research priority as well.”
“A statistical model using kallikrein markers better predicted high-grade prostate cancer in men with elevated PSA levels and reduced unnecessary biopsies compared with PSA level and age alone, according to the results of a prospective analysis.
“ ‘Risk of death from prostate cancer is strongly associated with levels of PSA in blood measured in middle-aged men,’ Hans Lilja, MD, PhD, of Memorial Sloan Kettering Cancer Center, and colleagues wrote. ‘Evidence from randomized screening trials in Europe shows that PSA-based screening can reduce deaths from prostate cancer, but also leads to overdiagnosis and the risk of overtreatment among elderly men with a limited life expectancy.’
“Previous retrospective studies identified four kallikrein markers — free PSA, intact PSA, total PSA and human kallikrein-related peptidase 2 (hK2) — that can predict biopsy outcomes, according to study background.”
“Initial results from the Göteborg randomised screening trial indicates that using MRI (Magnetic Resonance Imaging) alongside conventional prostate cancer screening seems to offer improved cancer detection and can help avoid unnecessary biopsies.
“Prostate cancer is the third most common male cancer in Europe, accounting for over 92,000 deaths in 2012 (9% of male deaths). Screening for prostate cancer is a controversial issue, with until recently, little clear evidence that existing screening procedures, using PSA (to be followed by biopsies), were effective. In general, either the screening has tended to miss many cancers, or to give false positives, meaning that many men are subject to invasive testing and perhaps treatment which was just not necessary.
“The Göteborg Trial is the Swedish arm of the European Randomized Study of Screening for Prostate Cancer (ERSPC), which is the largest randomized prostate cancer screening trial in the world. In 2014 results from this trial showed a significant mortality reduction with prostate-specific antigen (PSA) screening for men aged 55-69 years of age. Now new work, presented at the European Association of Urology Conference in Madrid, shows that using MRI may further improve the accuracy of prostate cancer screening. This research has been awarded the EAU’s First Prize for the Best Abstract by a Resident.”
“In a study reported in The Lancet, Hersch et al found that use of a decision aid containing information on overdetection in breast cancer screening was associated with an increased rate of informed choice regarding screening, a reduced rate of positive attitudes toward screening, and reduced intention to be screened.
“In the community-based trial conducted in New South Wales, Australia, 879 women aged 48 to 50 years who had not had mammography in the past 2 years and did not have a personal or strong family history of breast cancer were randomly assigned between January 2014 and July 2014 to receive an intervention decision aid including evidence-based explanatory and quantitative information on overdetection, breast cancer mortality reduction, and false-positives (n = 440) or a control decision aid including information on breast cancer mortality reduction and false-positives (n = 439). The primary outcome was informed choice, defined as adequate knowledge and consistency between attitudes and screening intentions. Participants were interviewed via telephone at 3 weeks after randomization. The primary outcome was analyzed in all women who completed all follow-up interview questions.
“Among the two cohorts, 21 women in the intervention group and 20 in the control group were lost to follow-up, and 10 and 11 did not answer all interview questions. Among 409 women in the intervention group and 408 in the control group, 99 vs 63 (24% vs 15%, difference = 9%, P = .0017) were considered to have made an informed choice regarding screening. Compared with the control group, significantly more women in the intervention group met the threshold for adequate overall knowledge (29% vs 17%, difference = 12%, P < .0001), significantly fewer expressed positive attitudes toward screening (69% vs 83%, difference = 14%, P < .0001), and significantly fewer intended to be screened (74% vs 87%, difference = 13%, P < .0001).”
“Women who understand the risk of over-detection and over-diagnosis associated with mammography screening have lower intentions to have a breast screening test, according to a new Lancet study.
” ‘Mammography screening can reduce breast cancer deaths but most women are unaware that inconsequential disease can also be detected by screening, leading to over-diagnosis and overtreatment,’ says study author, Prof Kirsten McCaffery of the University of Sydney.
“Over-detection and over-diagnosis refers to the diagnosis and treatment of breast cancer that would not have presented clinically during a woman’s lifetime.
“Such a diagnosis, and the resulting overtreatment, can harm women physically and emotionally.”