In the board game Go, two players alternate in placing either black or white stones on a crosshatch wood board. The object is to form a pattern that surrounds the opponent. The game can involve dozens of stones in harmony between defense and counter-attack. Toward the end of a game, the Go board may appear as nothing more than an arbitrary array of black and white stones with sparse glimpses of wood for remaining play. This is the critical point in the game. To win, a player must find a cohesive pattern amidst the seemingly random.
Urology may be approaching its own critical point in the game of prostate cancer. The USPSTF is prepared to recommend against routine PSA screeningfor prostate cancer. The most comprehensive studies in prostate cancer screening have yet to find overall mortality benefits. Headlines misinterpreting research run throughout the national press. Prominent primary care physicians denounce shared decision-making between physician and patient in PSA screening. All of this is occurring at a time when the U.S. population is growing older.
Physicians are taught to think of diseases along a spectrum of differentiation and progression. When I call a consult for renal failure, the first question from the nephrologist is, “pre-renal or renal?” Congestive heart failure is either “compensated” by the rest of the cardiovascular system, or it isn’t. Endocrine pathologies are either “primary” or “secondary” disorders.
Why is prostate cancer still, well, just prostate cancer?
The debate on PSA screening encircles a nebulous, “catch-all” definition of prostate cancer that gravitates around minimizing biopsy and treatment complications in patients who could live otherwise normal lives with disease. The difference between low-risk and high-risk prostate cancer is de-emphasized (or ignored altogether). We can safely monitor low-risk prostate cancer for years, sometimes a patient’s remaining life, without intervention. However, the benefits of early detection and treatment of high-risk prostate cancer are clear. Indeed, the PSA debate ought to focus on ways to improve detecting high risk prostate cancer.
The USPSTF recommendation is currently a draft. If finalized, its influence on primary care providers and the public may impede the detection and treatment of high risk prostate cancer in men for years to come.
Prostate cancer is approaching a critical mass. Urology must dichotomize prostate cancer in terms of detection, treatment, and survivability. Most of the evidence is already in place.
We’re close. Just one or two moves away.