Active Surveillance for Prostate and Thyroid Cancers: Evolution in Clinical Paradigms and Lessons Learned - Beyond the Abstract
Much of the overdiagnosis and overtreatment of clinically insignificant prostate cancer is the result of broad population-based screening based on prostate-specific antigen-based (PSA) levels in asymptomatic men. To minimize the overdetection and the overtreatment of insignificant prostate cancer, the U.S. Preventive Services Task Force (USPSTF) recommends an individualized approach to screening for men 55–69 years old that includes shared decision-making.3
Active surveillance, which has been in use for over two decades, is recommended as a way to manage localized prostate cancer.4 Though there is no standardized active surveillance protocol, all protocols delay until cancer progression indicates treatment is required.4,5 Although the field has identified potential molecular markers that could potentially identify more aggressive tumors, no such marker exists and is still a critical unmet need.6
Unlike prostate cancer, thyroid cancer has no blood test like the PSA test that can identify individuals at increased risk for cancer. Rather, overdetection of PTCs is attributable to the introduction of high-sensitivity imaging techniques.7 Currently, many professional organizations make no recommendation on screening for thyroid cancers.8-11 However, the USPSTF12 and the American Academy of Family Physicians8 recommend against screening for thyroid cancers using neck palpation or ultrasonography. If a more effective screening method becomes available for thyroid cancer, we can apply the lesson from screening for prostate cancer and use an individualized approach that includes shared decision-making.
Studies of active surveillance for the management of PTCs is still in its infancy in the United States. The first studies of active surveillance for PTCs took place in multiple institutions in Japan.13-16 The findings from these studies have served as the basis for current active surveillance protocols that are underway. Similar to prostate cancer, thyroid cancer does not have the benefit of consensus regarding the modality of tests nor the frequency of testing for active surveillance protocols. Identification of a molecular marker to identify aggressive tumors has evaded researchers and its absence remains a critical gap.
Thus, the key lessons that we can apply from the management of localized prostate cancer to PTCs include steps that can be included from detection to management. We first have to have an effective and individualized approach to identifying who should undergo screening and when. Second, after diagnosis, we need consensus on how to stratify patients by risk and monitor in active surveillance protocols. Finally, we need to continue to search for meaningful molecular markers that can differentiate aggressive tumors from those that would do no harm.
Written by: Lisa M. Lowenstein1, Michelle D. Williams2, and Jeri Kim3
1. Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
2. Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
3. Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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References:
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