Medscape Medical News asked Vickers to speculate on how long the incidence of advanced prostate cancers will continue to rise in the United States.
“It would surprise me if we had bottomed out [and reached peak increases in advanced cancers] or if we had much longer to go,” he said. “My prediction is that if nothing were to change we will probably see some further increases in [the incidence of] advanced disease.”
What needs to change? Vickers ticked off a list of “golden rules.”
- First, physicians need to get consent for all PSA tests.
- Second, PSA tests should not be administered to older men “who won’t benefit,” such as men 75 years and older with comorbidities such as heart disease.
- Third, PSA testing should be restricted to younger men.
- Fourth, clinicians need to be more restrictive about biopsy. “It used to be if you had a high PSA, you would get a biopsy,” he said, adding that this approach yielded a lot invasive testing in men with low-grade disease. By using additional tests such as the 4Kscore or Prostate Health Index or MRI, clinicians can limit biopsies to men with greater likelihood of a high-grade cancer. Vickers acknowledged conflict of interest on this point, as he is a patent holder of the 4Kscore.
- Fifth, don’t treat men who are very unlikely to benefit, especially men with Gleason grade 6 disease. Use active surveillance for these men, he said. “Using our existing knowledge, I believe we can completely transform the harm-to-benefit ratio of PSA screening. We would drastically reduce overdiagnosis and overtreatment,” he stated.
Additionally, Vickers believes that urologists need to educate local internists and general practitioners and acknowledge that screening and subsequent treatment were “done wrong for a long time.” At the same time, urologists should make it clear that patients will not be biopsied “unless there is a really good reason to believe that they have a high risk of high-grade disease.”
Vickers concluded: “We can reduce the harm and maintain the benefit of screening.”
The study was supported by the American Cancer Society. Jemal and Shabsigh have disclosed no relevant financial relationships. Vickers declared that he is a patent holder of the 4Kscore.
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