Screening for Prostate Cancer – 2018 Clinical Update for Medical Professionals
Dr. Alex Shteynshlyuger is a fellowship-trained urologic oncologist, a robotically-trained surgeon who specializes in all aspects of care for early, advanced and metastatic prostate cancer. He is a member of the Society for Urologic Oncology as well as American Society for Clinical Oncology.
History of Screening for Prostate Cancer
Prostate cancer is the most common solid cancer that affects men with 12-15% lifetime risk of diagnosis. It is the cause of death in 3% of men in the US and a far greater morbidity due to complications of metastatic prostate cancer.
PSA test has been used as a screening test for early detection of prostate cancer starting in the late 1980’s. As a screening test, PSA suffers from relatively poor specificity at values less than 10 ng/dl. This has led to overdiagnosis of low-risk prostate cancer. Randomized controlled studies have also shown decreased metastatic disease burden and improved prostate-cancer mortality among screened men (ERSPC). However, overtreatment is both costly and associated with significant morbidity.
Innovations in Prostate Cancer Screening – 2018 Perspective
With >32,000 deaths from prostate cancer per year in the US alone, early detection of disease that is destined to become metastatic and cause morbidity and death present a desirable goal. The goal is to balance the risks of overdiagnosis and overtreatment of less aggressive disease that may never become clinically relevant with the benefits of early detection of aggressive disease.
Approaches to Improve Detection of High-Risk Prostate Cancer and Minimize Overdiagnosis / Overtreatment
The search for a perfect screening test is still on to replace the PSA test. A number of promising approaches are available. One is to use a better screening test. Here we have a few tests to choose from: PHI (prostate health index) test has improved the ability to separate men with elevated PSA into those who are more likely to have prostate cancer from those who are more likely to have benign disease. PHI test can prevent unnecessary biopsies.
The 4KScore test is designed to separate men with high risk for aggressive prostate cancer from those with no prostate cancer and low-risk prostate cancer.
Another option is to choose men with a higher risk for aggressive disease by stratifying lower Gleason biopsy results using molecular and genetic markers.
Molecular and Genetic Approaches to Patient Stratification
A number of molecular and genetic markers have been identified that predict a higher risk of high-risk prostate cancer. Screening for prostate cancer with tests that have higher specificity for high-risk prostate cancer holds the promise of curing men with clinically significant disease (that is likely to become metastatic and cause death) while avoiding overtreatment.
A number of genetic mutations including ERG and PTEN have been identified that put men at higher risk for metastatic disease and death. A number of commercial tests including PersonalizedDx FISH test for ERG+ and PTEN aim to improve prognostication for men diagnosed with prostate cancer. This will allow us to better select men for active surveillance who are low risk and those at higher risk for active treatment.
Surgical Treatment of Prostate Cancer
The future of prostate cancer treatment is closely tied to surgical treatment. While fewer lower risk cancers are being treated surgically, we are going to see an expansion of surgery used in later-stage disease including metastatic disease.
The interim upgrade of DaVinci Robotic system to DaVinci Xi is a step toward utilization of the robotic system in more exquisite situations requiring advanced manipulation and access such as metastasectomy and extended lymph node dissections.
Improved sensitivity of screening tests for high-risk disease allows us to detect high-risk cancer while avoiding the problem that plagued PSA as a screening test, namely overdiagnosis. 4KScore appears to be most promising in this regard with PHI being useful as well. Combined with genetic profiling of prostate biopsies, our new tools allow us to only select men who are at high risk for symptomatic disease for treatment while allowing a safer approach to active surveillance for men who are at low risk of experiencing morbidity of prostate cancer.
Improved efficacy of treatment, such as Zytiga, Xtandi, Xofigo and Provenge that lead to improved overall survival in RCTs (randomized controlled trials) provide further rationale for high-impact screening for high-risk prostate cancer.
We see patients from all parts of New York City (Manhattan, Brooklyn, Queens, Bronx, Staten Island), Long Island, Westchester and New Jersey as well as other parts of the USA. We also see international patients from Canada, Japan, South America, Russia, Asia, Europe, Middle East, Africa, the Caribbean and other parts of the world.