Prostate cancer diagnosis must be precise and complete. 1
Prostate cancer diagnosis has to be correct, precise and complete. Can you overdiagnose prostate cancer? Prostate cancer overtreatment. Diagnostic methods for prostate cancer are changing. Precision medicine has now reached prostate cancer. Dr. Anton Titov, MD. Prostate cancer is an umbrella term for tumors with different characteristics. Prostate cancer diagnostic tests and treatment strategy are constantly evolving and have become complex. What is the diagnostic path to precise and complete diagnosis of prostate cancer? Dr. Mark Emberton, MD. So this is a really interesting question. It is one that’s changing as we speak. It’s interesting to look at other cancers and the way that the cancer diagnosis has evolved. For instance, the diagnosis of kidney cancer was made clinically by feeling a lump or seeing blood in the urine. It was ultrasound and CT scanning of kidney that allowed us to detect kidney cancer earlier. CT allowed us to have much more complex description of what was present in the kidney. Indeed, it was CT scanning that allowed us to start to see the cancer within the kidney. We could plan surgery in a way that we could remove just the cancer. We could leave as much kidney tissue preserved. This is “nephron sparing”surgery. Surgery has resulted in many patients living longer because of an avoidance of kidney failure. I think probably the most talked about example of precision medicine treatment is the breast cancer. So 40 or 50 years ago every woman had a mastectomy. Mastectomy is a removal of the front part of the chest wall. It’s huge operation. But that was first the only operation you could have for breast cancer. And then with mammography we could identify the cancer within the breast. We could decide whether a smaller operation would be sufficient. Clinical trials supported minimally invasive treatment. In many women removing a breast cancer lump is as effective as removing the whole anterior chest wall with all the problems that come with it. Dr. Anton Titov, MD. Cancer Surgery becomes minimally invasive. Dr. Mark Emberton, MD. Correct! And in prostate cancer minimally invasive treatment hasn’t happened yet! We’ve been removing the whole prostate gland or irradiating the whole prostate gland. Our target has been the prostate gland itself. That’s why for the last 50 or 60 years we’ve been putting needles into the prostate in a blind manner. We do not really know where is the cancer. We are trying to identify whether the patient has cancer or doesn’t have cancer. If the patient had cancer, we would remove the prostate gland. If patient didn’t have cancer, we would discharge them. And it’s been like that for a long time. That meant that men were misdiagnosed with prostate cancer. We missed a lot of prostate cancers. Men had prostatectomy, removal of the prostate, many times unnecessarily. They had very low risk prostate cancer disease that wouldn’t have killed them had prostate been left in place. And some of you will have heard, some of listeners will have heard, things about cancer overdiagnosis and cancer overtreatment. Prostate cancer was the worst offender in overdiagnosis. A lot of people were treated for prostate cancer. Very few people benefited from prostate cancer therapy. And that’s the revolution. And the last revolution is in prostate cancer diagnosis. It’s really the advent of MRI, magnetic resonance imaging, which doesn’t involve any radiation. Dr. Mark Emberton, MD. And many of the listeners and the people watching this will have had MRI for their knees, hips and maybe even their head. But we are directing MRI technology to the prostate. We are using a lot of special MRI sequences to tell us where the cancer is within the prostate gland. And once we do MRI, we can diagnose the patients with great precision. We can put the needle into the prostate cancer itself. That makes for much more meaningful diagnosis. But it also opens up the opportunity to treat the cancer patient in an individual way. So if all you want to do is remove the prostate, every prostate carcinoma patient gets the same treatment. If what you want to do is to treat the cancer optimally, you might operate differently. If the cancer is on the left or the right, you might put more radiation where the cancer is and less radiation elsewhere. Or you might even try and just treat the cancer itself and preserve the prostate. Thereby you can preserve urinary continence and also erectile function. These are two problems that are very very common when we treat the whole prostate gland for cancer.
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