GU Cancers 2019 | Who should be biopsied for prostate cancer screening?

What we think should happen, and in fact what we’re seeing a lot of practice throughout the US now is a much more selective approach to biopsy particularly, with the use of molecular markers free to total ratio for case score prostate health index or the use of MRI. So instead of saying ‘oh you’ve got a high PSA I’ll a biopsy you say oh well you’ve got a high PSA that’s that’s of concern’. Let’s do some more tests and then decide to biopsy, only if you’re at increased risk of having a high grade cancer.

The other question of course is how we treat the main harms from PSA screening as over treatment. Yes over diagnosis is a problem. No one wants to hear unnecessarily ‘You have cancer’, that’s traumatic for a patient. But that’s not half as bad as having long-term urinary erectile or bowel dysfunction. So we can reduce over treatment predominantly by not treating men with locally some great cancer and obviously for many years we were treating pretty much everybody with prostate cancer. And then it was well we wouldn’t treat you if you had Gleason 6 disease great group one I met all these other criteria. PSA had to be low and you couldn’t have high stage disease and you couldn’t have too many cause involved. The number of millimeters and so on and so forth and in fact those don’t really matter if you have Gleason 6 disease you can be put safely on active surveillance and that would cut the amount of over treatment by at least a half.