PHEN Addressing Prostate Cancer Overtreatment

By: Thomas A. Farrington

PHEN President and Founder

Member, National Comprehensive Cancer Network (NCCN) Prostate Cancer Treatment Guidelines Panel 

"I have talked with men on hormone (androgen deprivation) treatment as their first and primary treatment, and I always wonder whether they know that this treatment is not a potential cure for prostate cancer even though it may lower the PSA."

The quote above was taken from my first book, "Battling the Killer Within," published in 2001. 
A Recent Study showed that among patients whose cancer was not aggressive, those who received hormone therapy as their primary treatment did not live any longer than those who were merely carefully monitored. However, the side effects from this treatment can be severe.

The issue of overtreatment in prostate cancer is real and I am glad that it is receiving more visibility and attention. PHEN addressed this issue directly when we released our "Consensus Statement on PSA testing for African American Men" in September 2013, which included this statement:

"Consensus Statement 3: A prostate cancer diagnosis must be uncoupled from prostate cancer intervention. Although early detection is essential to diagnose high-risk cases within the window of curability, it is clear that many men with low-risk prostate cancer do not need immediate aggressive treatment. With an incidence rate 1.6 times higher than other men, African Americans, as a group, are at an increased risk for over-treatment and potentially suffering unnecessary harms from such treatments. Men should be counseled about their treatment options and caution should be exercised to prevent over-treatment. Active surveillance protocols have been developed and have been shown to be a reasonable and safe option for many men with low-volume, low-risk prostate cancer. However, there is published evidence that African American men are more likely to fail active surveillance protocols than men of other ethnicities. While it is accepted that active surveillance does not address the issue of over-diagnosis, it does provide a vehicle to avoid excessive intervention. Active surveillance strategies need standardization and validation to reassure patients, especially African Americans, and clinicians that this is a safe strategy. The NCCN Prostate Cancer Treatment Guidelines have offered excellent guidance in this area, and an ever-expanding medical literature and informative clinical trials assure continued refinement and confidence in this strategy. In addition there are new prognostic tests currently available and others in various stages of scientific and clinical validation to help determine if the cancer is life threatening."

At PHEN's "9th Annual African American Prostate Cancer Disparity Summit" in September 2013 we hosted a session on active surveillance with two great presentations: 
H. Ballentine Carter, MD - "The Evidence Suporting Active Surveillance" ; Edward M. Schaeffer, MD, PhD - "Active Surveillance and African Americans; A Study's Findings" 

As a part of PHEN's "Prostate Health Minute" personal services announcements, broadcast by our national radio partners, PHEN released this message in April, 2014; 
To Treat or Not to Treat Prostate Cancer.

I agree with Dr. Otis Brawley's position in his recent CNN article: 
"Epidemic of Overtreatment of Prostate Cancer Must Stop." , and I concur with his position that patient education and awareness organizations have a responsibility to their constituents to address overtreatment. However, I disagree with a de-emphasis of early detection PSA testing, as reccomended by the U.S.Preventive Services Task Force (USPSTF). This approach puts men who can benefit most from early detection and early intervention at greater risk by delaying detection and treatment until symptons appear. Medical experts say this may be too late to provide any type of curative treatment.

While there is current movement to reduce overtreatment we mus
t be cautious in educating men and their families about who is a candidate for active surveillance, and who needs immediate aggressive treatment. Active surveillance is not intended to save lives from prostate cancer as it should be reserved for those men whose lives are not at risk from the disease. The challenge is to accurately identify men who should choose active surveillance without putting those men who need immediate aggressive treatment at greater risk.  

Today, there are some exciting genomic based prognostic tests that are helping to meet this challenge. Making men aware of these tests and how they can access them is a current area of focus for PHEN. We held a session at our 2013 summit entitled: "Prognostic Tests to Help Determine if the Cancer is Life-Threatening." The session included these presentations: 
Bela S. Denes, MD, - Genomic Health  and Michael Brawer, MD - Myriad.

PHEN will continue its leadership role in educating our constituents about the issue of prostate cancer overtreatment as "knowledge is the best defense against prostate cancer." We continually interface with medical experts and the pharmaceutical industry for access to the most current information available to meet the great need for education and awareness in this rapidly evolving area.

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