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Reply from Authors re: Peter C. Albertsen. How Best To Use Our Tools? Eur Urol 2012;62:201–2
EUROPEAN UROLOGY 62 (2012) 201–203
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Platinum Priority Reply from Authors re: Peter C. Albertsen. How Best To Use Our Tools? Eur Urol 2012;62:201–2 Meelan Bul *, Monique J. Roobol Department of Urology, Erasmus MC, Rotterdam, The Netherlands
We appreciate the comments from Albertsen [1] in response to our paper [2]. He highlighted some of the controversies and obstacles in prostate cancer (PCa) screening that have yet to be conquered [1]. Although it has been shown that screening for PCa can reduce disease-specific mortality by up to 30% [3,4] or even more [5,6], the shortcomings of screening regarding the number of false-positive tests and overdiagnosis are evident. Hence we are aware of the side effects of screening, and the challenge we face is to look for solutions. There is still a lot of work to do in finding new, better, and more selective markers for screening purposes and to keep improving nomograms for risk stratification to achieve better predictions [7]. Ideally, either there would be no overdetection of disease that will not surface clinically during the patient’s lifetime or radical treatment would be free from any side effects. Unfortunately, to date, neither of these ideals can be realized. In that respect, we have to keep both feet on the ground and acknowledge that there is no time to wait for scientific certainty; no perfect marker is available for selective detection of significant PCa, and such a marker might never be found. Consequently, in current practice, we shall make do with what we have and implement the best available evidence in practice. For now, this implies that decisions about screening should be made on an individual basis, after providing the patient with information about his potential risks and benefits. Even though the natural course of PCa is not completely clear, it is plain to see that in the prostate-specific antigen era, a lot of indolent disease is being detected, making active surveillance (AS) a sensible alternative as a management strategy for patients in whom such low-risk disease is suspected. Regarding the considerable difficulties in implementing trials randomizing for radical treatment and AS [8], answers to important questions on long-term mortality and inclusion
DOIs of original articles: 10.1016/j.eururo.2012.02.002, 10.1016/j.eururo.2012.02.044 * Corresponding author. Erasmus MC, University Medical Centre Rotterdam, Department of Urology, Room NH-224, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel. +31 10 7032243; Fax: +31 10 7035315. E-mail address: [email protected] (M. Bul).
and follow-up criteria for AS are more likely to come from prospective AS studies [9]. We hope that with the data of our Web-based, multinational Prostate Cancer Research: Active Surveillance (PRIAS) study, we will contribute to the improvement of eligibility criteria and follow-up protocols for men with favorable-risk disease. In the meantime, the search for the perfect marker continues, and we will carry on with providing the best care available today to our patients. Conflicts of interest: The authors have nothing to disclose.
References [1] Albertsen PC. How best to use our tools? Eur Urol 2012;62:201–2. [2] Bul M, Zhu X, Rannikko A, et al. Radical prostatectomy for low-risk prostate cancer following initial active surveillance: results from a prospective observational study. Eur Urol 2012;62:195–200. [3] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostatecancer mortality in a randomized European study. N Engl J Med 2009;360:1320–8. [4] Roobol MJ, Kerkhof M, Schro¨der FH, et al. Prostate cancer mortality reduction by prostate-specific antigen-based screening adjusted for nonattendance and contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC). Eur Urol 2009;56:584–91. [5] Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11:725–32. [6] Schro¨der FH. Screening for prostate cancer: a critical update from ERSPC at 11 years’ follow-up [webcast]. Presented at: 27th Annual Congress of the European Association of Urology; February 24–28, 2012; Paris, France. http://webcasts.prous.com/eau2012/html/1en/template.aspx?section=12&v=S. Accessed March 1, 2012. [7] Roobol MJ, Steyerberg EW, Kranse R, et al. A risk-based strategy improves prostate-specific antigen-driven detection of prostate cancer. Eur Urol 2010;57:79–85. [8] Klotz L, Kibel A, Sanda M. Observation or radical treatment in patients with prostate cancer [identifier NCT00499174]. ClinicalTrials.gov Web site. http://clinicaltrials.gov/ct2/show/NCT00499174?term= NCT00499174&rank=1. [9] Montironi R, Egevad L, Bjartell A, Berney DM. Role of histopathology and molecular markers in the active surveillance of prostate cancer. Acta Oncol 2011;50(Suppl 1):56–60. doi:10.1016/j.eururo.2012.03.001
203
Platinum Priority Reply from Authors re: Peter C. Albertsen. How Best To Use Our Tools? Eur Urol 2012;62:201–2 Meelan Bul *, Monique J. Roobol Department of Urology, Erasmus MC, Rotterdam, The Netherlands
We appreciate the comments from Albertsen [1] in response to our paper [2]. He highlighted some of the controversies and obstacles in prostate cancer (PCa) screening that have yet to be conquered [1]. Although it has been shown that screening for PCa can reduce disease-specific mortality by up to 30% [3,4] or even more [5,6], the shortcomings of screening regarding the number of false-positive tests and overdiagnosis are evident. Hence we are aware of the side effects of screening, and the challenge we face is to look for solutions. There is still a lot of work to do in finding new, better, and more selective markers for screening purposes and to keep improving nomograms for risk stratification to achieve better predictions [7]. Ideally, either there would be no overdetection of disease that will not surface clinically during the patient’s lifetime or radical treatment would be free from any side effects. Unfortunately, to date, neither of these ideals can be realized. In that respect, we have to keep both feet on the ground and acknowledge that there is no time to wait for scientific certainty; no perfect marker is available for selective detection of significant PCa, and such a marker might never be found. Consequently, in current practice, we shall make do with what we have and implement the best available evidence in practice. For now, this implies that decisions about screening should be made on an individual basis, after providing the patient with information about his potential risks and benefits. Even though the natural course of PCa is not completely clear, it is plain to see that in the prostate-specific antigen era, a lot of indolent disease is being detected, making active surveillance (AS) a sensible alternative as a management strategy for patients in whom such low-risk disease is suspected. Regarding the considerable difficulties in implementing trials randomizing for radical treatment and AS [8], answers to important questions on long-term mortality and inclusion
DOIs of original articles: 10.1016/j.eururo.2012.02.002, 10.1016/j.eururo.2012.02.044 * Corresponding author. Erasmus MC, University Medical Centre Rotterdam, Department of Urology, Room NH-224, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel. +31 10 7032243; Fax: +31 10 7035315. E-mail address: [email protected] (M. Bul).
and follow-up criteria for AS are more likely to come from prospective AS studies [9]. We hope that with the data of our Web-based, multinational Prostate Cancer Research: Active Surveillance (PRIAS) study, we will contribute to the improvement of eligibility criteria and follow-up protocols for men with favorable-risk disease. In the meantime, the search for the perfect marker continues, and we will carry on with providing the best care available today to our patients. Conflicts of interest: The authors have nothing to disclose.
References [1] Albertsen PC. How best to use our tools? Eur Urol 2012;62:201–2. [2] Bul M, Zhu X, Rannikko A, et al. Radical prostatectomy for low-risk prostate cancer following initial active surveillance: results from a prospective observational study. Eur Urol 2012;62:195–200. [3] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostatecancer mortality in a randomized European study. N Engl J Med 2009;360:1320–8. [4] Roobol MJ, Kerkhof M, Schro¨der FH, et al. Prostate cancer mortality reduction by prostate-specific antigen-based screening adjusted for nonattendance and contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC). Eur Urol 2009;56:584–91. [5] Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11:725–32. [6] Schro¨der FH. Screening for prostate cancer: a critical update from ERSPC at 11 years’ follow-up [webcast]. Presented at: 27th Annual Congress of the European Association of Urology; February 24–28, 2012; Paris, France. http://webcasts.prous.com/eau2012/html/1en/template.aspx?section=12&v=S. Accessed March 1, 2012. [7] Roobol MJ, Steyerberg EW, Kranse R, et al. A risk-based strategy improves prostate-specific antigen-driven detection of prostate cancer. Eur Urol 2010;57:79–85. [8] Klotz L, Kibel A, Sanda M. Observation or radical treatment in patients with prostate cancer [identifier NCT00499174]. ClinicalTrials.gov Web site. http://clinicaltrials.gov/ct2/show/NCT00499174?term= NCT00499174&rank=1. [9] Montironi R, Egevad L, Bjartell A, Berney DM. Role of histopathology and molecular markers in the active surveillance of prostate cancer. Acta Oncol 2011;50(Suppl 1):56–60. doi:10.1016/j.eururo.2012.03.001