There would be 775,000 cases of prostate cancer if we biopsied all patients with a PSA over 2.5ng/ml said Dr. Klotz. Using a surveillance strategy at the University of Toronto, there is <1% likelihood of prostate cancer mortality. The few deaths occurred early, suggesting existing metastatic disease at the time of diagnosis. A PSA doubling time of <3 years for prompting intervention resulted in a positive surgical margin in 33% and grade progression in 22%. Analysis of PSA criteria that would prompt intervention demonstrated that using the D'Amico criteria of a PSA velocity >2ng/ml would result in 49% converting to active treatment. Focusing on patients with low volume, low grade disease, it would require 37 radical prostatectomies to prevent one CaP death. If surveillance and salvage definitive therapy were employed, up to 90 radical prostatectomies would be done to save one life from a CaP death.

Dr. Gary Onik, Celebration Health presented the "The Case for Focal Therapy". He made the analogy to breast cancer and the fact that lumpectomy is often primary therapy. He discussed a detailed prostate biopsy-mapping schema to better identify all CaP sites prior to treatment. Bilateral CaP was found in 55% of 110 cases that was usually not detected by routine biopsy schemas. Gleason score was increased in 23% of these patients. They then underwent a focal cryotherapy procedure. Follow-up included 7-core biopsies. Of 96 evaluable patients at a mean of 3.6 years, 95% are biochemically disease free. 7% required retreatment due to CaP in untreated gland areas. All post procedure biopsies were negative in the 26 who received biopsies. 86% of those potent prior to the cryo remained so. All were continent. Dr. Onik also discussed using electrical pulsed therapy (electroporation) to damage cell integrity in a focal application. This is not dependent on blood flow to the tissue. This type of ablation provides an example of focal therapy that offers an intermediary approach between active surveillance and active treatment.

Dr. Jim Montie, Michigan gave the "The Case for Definitive Therapy". He agreed that there is much over-treatment of CaP. In patients with biopsy Gleason score 6 tumors, it is upgraded in 20-30%. He felt that improved sampling techniques would help with this. He argued that breast cancer lumpectomy is not analogous to CaP, as women undergoing breast cancer lumpectomy also receive radiotherapy to the rest of the breast to treat multifocality. He favored either active surveillance or definitive therapy as opposed to focal therapy. Unnecessary treatment (whether over-treatment or under-treatment) is always bad treatment, he concluded.

Dr. Freddie Hamdy, University of Sheffield presented "The Case for a Coin Flip: START and PROTECT". The START trial randomizes between active treatment and active surveillance for favorable CaP. The primary endpoint is disease specific survival, and a tissue and serum bank will be collected. The PROTECT study evaluates screen detected CaP at 9 UK centers. Nurses and urologists will accrue men to randomization for surgery, radiotherapy or non-immediate intervention. 7,000 men comprised a feasibility study. Those who had CaP diagnosed by an urologist were randomized first to a consulting session by an urologist or nurse who then discussed treatment randomization as described. Most important, said Dr. Hamdy was explaining the trial and education about CaP prior to a diagnosis of CaP. If surgery was discussed first and active surveillance last, it was more likely that surgery was desired. Reassuring the patient that their welfare was of greater import than the clinical trial was also critical. This feasibility study has now progressed to a larger trial in which 77,869 men attended clinic visits.

During case presentations, the general panel consensus was that no clear single intervention has clear-cut benefit. Drs. Blute, Mayo Clinic and Montie favored radical prostatectomy as definitive therapy, especially in those with Gleason score 7 disease.

Report from The Society of Urologic Oncology Winter Meeting - National Institutes of Health - December 1-2, 2006

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Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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