The term “cancer” dates to the time of Hippocrates, when the crab (karkinos)-like cutaneous manifestations of advanced tumors heralded incurable disease, pain, decline, and death. Today the term denotes an incredibly diverse spectrum of conditions, all characterized by abnormal cell division and growth—and nearly all by the capacity for metastasis—but varying very widely in aggressiveness and kinetics of progression. In the era of microscopy and histopathology, each cancer now has its formal criteria for diagnosis, and clinicians recognize the variable meaning of each. To the public, however, the connotation of the diagnosis “You have cancer” has changed only to an extent in the modern age.

In the case of prostate cancer, prostate specific antigen (PSA)-based early detection and the years-to-decades lead time associated with screening has radically changed the clinical meaning of the diagnosis. Countless research articles and reviews on prostate cancer begin by citing the fact that it is the most common non-cutaneous cancer diagnosed among men in the US and in many other countries.
The 2022 American Urological Association (AUA) Annual Meeting is now underway (in person!) in New Orleans, and this week, the AUA released an updated guideline for localized prostate cancer, again working jointly with the SUO and ASTRO. The guideline includes many notable updates and changes, but one of the most important is the removal of the “very low” risk category and explicit endorsement of active surveillance as “preferred” management for all low-risk disease.

This change is timely, and particularly notable in contrast to the NCCN guideline, which last year not only reiterated the “very low risk” category but transiently removed “preferred” from its listing of surveillance for “low risk” disease, endorsing prostatectomy and radiation as equivalent alternatives. The NCCN reversed this decision a few months later, and now once again states that surveillance is “preferred,” though with multiple caveats and exceptions. So which guideline is more relevant for contemporary practice?

The year 2020 will be remembered for many reasons, few of them good. But among the fires, floods, locusts, and other natural disasters, two tsunamis have swept the country and the world, unequaled in a generation. The first, of course, is the COVID-19 pandemic; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19), the other is a groundswell of support for racial justice unequaled in breadth and impact since the civil rights movement over a half-century ago. Both have been met with breathtaking indifference and incompetence by a federal government whose three branches have been rendered virtually powerless by the small-minded machinations of a reactionary minority.

As most who find their way to doubtless already know, prostate cancer remains by far the most common non-cutaneous cancer diagnosed, and the second leading cause of cancer death among American men. Worldwide, prostate cancer is steadily rising in both incidence and mortality, with over a 1.1 million new diagnoses and 300,000 deaths annually. In the United States, in the era of PSA-based early detection efforts,

incidence rates have waxed and waned with shifting guidelines and prevalence of PSA testing. Age-adjusted mortality rates have fallen over 50%—the steepest decline of any cancer except lung cancer—and the best statistical models attribute a substantial majority of this decline to screening and to improvements in treatment for localized disease.