Are we overtreating low risk prostate cancer?

Vera Donoso, C.D.

doi:10.1016/j.acuroe.2011.06.016

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Overdiagnosis and overtreatment are, very likely, the most significant adverse effects of PCa screening.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Despite therapeutic advances, the consequences of the disease and the treatment given itself affect the patient's quality of life for years.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The recent annual congress of the American Urological Association, held in Washington, had an area that we could qualify as historic. On May 17, 2011, Dr. Timothy Wilt, professor of Medicine at the University of Minnesota, presented the results of the PIVOT study (Prostate Cancer Intervention Versus Observation Trial). Started in 1994, this study included 731 patients who agreed to be randomly subjected to radical prostatectomy (RP) or maintain watchful waiting (WW). In order to be eligible, patients had to be <75, have clinically localized PCa, and PSA <50ng/ml. The average age was 67. The mean and median PSA were 10.2 and 7.8ng/ml, respectively. According to the classification of tumor risk, approximately 40% had low-risk tumors, 33% intermediate-risk tumors, and 22% high-risk tumors.At 12, 354 of the 731 men (48.4%) had died, with an absolute reduction in general mortality and disease-specific mortality of approximately 3% in the RP group compared to the WW group. In men with low-risk disease, there was an absolute difference in mortality of PCa between treatment groups of 1.4% for observation. But, in men with high-risk disease, the absolute difference was 8.4% for surgery (webcast on AUA website). The PIVOT shows that this ‘cancer’ does not imply an inexorable progression to metastasis and death.The increasing number of men diagnosed with PCa in Spain involves serious consequences. It places the psychological burden of the cancer diagnosis on thousands of patients and generates an unnecessary fear in them. In addition, it distracts attention, time, and material resources that are needed to identify the tumors that require aggressive treatment. In a recent Spanish work, the low-risk group was 43.3% of the patients undergoing RP, 25.5% of whom received external radiotherapy, and 96.7% of the patients who received brachytherapy.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>We must understand that this PIVOT study report is not ‘bad news’ but ‘good news’ because it points the way to be followed in the search for the truth and the benefit to our patients. Meanwhile, I propose some thoughts on what our attitude to follow should be:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.To accept that population screening and diagnostic examinations detect a considerable number of indolent tumors.</li><li class="elsevierStyleListItem" id="lsti0010">2.To redefine what low-risk PCa really is. To consider the elimination of the use of the word ‘cancer’ and its replacement by a term like ‘IDLE tumor’ (indolent lesions of epithelial origin).<a class="elsevierStyleCrossRef" href="#bib0020">4</a></li><li class="elsevierStyleListItem" id="lsti0015">3.To restrict the indication for prostate biopsies.</li><li class="elsevierStyleListItem" id="lsti0020">4.Genetics can help us differentiate between aggressive tumor phenotypes and indolent ones.</li><li class="elsevierStyleListItem" id="lsti0025">5.To propose, as suggested by the National Comprehensive Cancer Network guidelines (NCCN), active or watchful surveillance as the first therapeutic option in low-risk patients.</li><li class="elsevierStyleListItem" id="lsti0030">6.Last, but not least, to convey reassurance to our patients with a tumor that, obviously, will not kill them.</li></ul>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Vera Donoso CD. ¿Estamos sobretratando el cáncer de próstata de bajo riesgo?. Actas Urol Esp. 2012;36:66." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer screening" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Hakama" 1 => "A. Auvinen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "International encyclopaedia of public health" "paginaInicial" => "464" "paginaFinal" => "480" "serieFecha" => "2008" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Health related quality of life outcomes after radical prostatectomy: attention to study design and the patient-based importance of single-surgeon studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.L. Dalkin" 1 => "B.A. Christopher" 2 => "D. Shawler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urolonc.2005.05.009" "Revista" => array:6 [ "tituloSerie" => "Urol Oncol" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "28" "paginaFinal" => "32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16414489" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Grupo Multicéntrico Español de Cáncer de Próstata Organoconfinado" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Becerra Bachino" 1 => "F. Cots" 2 => "F. Guedea" 3 => "J. Pera" 4 => "A. Boladeras" 5 => "F. Aguiló" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gaceta.2010.10.008" "Revista" => array:6 [ "tituloSerie" => "Gac Sanit" "fecha" => "2011" "volumen" => "25" "paginaInicial" => "35" "paginaFinal" => "43" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21316126" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Solving the overdiagnosis dilemma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Esserman" 1 => "I. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/jnci/djq119" "Revista" => array:6 [ "tituloSerie" => "JNCI" "fecha" => "2010" "volumen" => "102" "paginaInicial" => "582" "paginaFinal" => "583" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20413743" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000003600000001/v1_201304251735/S2173578612000297/v1_201304251735/en/main.assets" "Apartado" => array:4 [ "identificador" => "6306" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000003600000001/v1_201304251735/S2173578612000297/v1_201304251735/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578612000297?idApp=UINPBA00004N"]

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Actas Urológicas Españolas is an international journal dedicated to urological diseases and renal transplant. It has been the official publication of the Spanish Urology Association since 1974 and of the American Urology Confederation since 2008. Its articles cover all aspects related to urology. Actas Urológicas Españolas, governed by the peer review system (double blinded), is published online in Spanish and English. Consequently, manuscripts may be sent in Spanish or English and bidirectional free cost translation will be provided. It has high visibility and accessibility and is found in the most important data bases, Medline/Pubmed, Emabase, JCR, Ïndice Médico Español, Índice bibliográfico Español en Ciencias de la Salud (IBECS), Cuiden, Dialnet, Hinari, Scopus, Google Scholar.

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Vol. 36. Issue 1.

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