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The New England Journal of MedicineDecision Making in Prostate Cancer

Balancing the Risks and Benefits of Radical Treatment vs. Active Surveillance in Prostate Cancer

In the complex landscape of prostate cancer management, healthcare professionals often face dilemmas in recommending the best course of action for their patients. A recent case study highlights the challenges in treating a 61-year-old man with elevated PSA levels and a family history of prostate cancer. The article delves into the pros and cons of radical treatment versus active surveillance, providing expert perspectives to aid in decision-making.

HCN Medical Memo
This case underscores the importance of a nuanced approach to prostate cancer treatment. Although elevated PSA levels and family history may point towards aggressive treatment, the patient’s quality of life, age, and specific medical findings must also be considered. Active surveillance could be a viable option for low-risk patients, but it requires regular monitoring and possibly further diagnostic tests. The decision should be a collaborative process, taking into account the most current research and guidelines, as well as the patient’s personal preferences and lifestyle.

Key Points
  • Patient Profile: 61-year-old man with a history of hypertension and obesity, family history of prostate cancer, and elevated PSA levels of 5.2 ng/mL.
  • Diagnostic Findings: Biopsy revealed low-grade adenocarcinoma with a Gleason score of 6.
  • Expert Opinion on Radical Treatment: According to Dr. Anthony V. D’Amico, the ProtecT trial suggests that active monitoring may result in higher rates of metastasis compared to radical treatments.
  • Expert Opinion on Active Surveillance: Dr. Jenny L. Donovan and Freddie C. Hamdy argue that active surveillance could be more appropriate given the patient’s low-risk profile and desire to maintain quality of life.
  • PSA Density as a Risk Factor: The patient’s PSA density is elevated at 0.22 ng/mL per cm³, which is considered a risk factor for adverse pathological findings.

The ProtecT trial showed that men diagnosed with clinically localized prostate cancer had a very low (2 to 3%) risk of prostate cancer–specific death after a 15-year median follow-up, regardless of the treatment approach.

Additional Points
  • MRI and Targeted Biopsies: Both experts recommend multiparametric MRI and targeted biopsies for a more accurate assessment of the cancer grade.
  • Quality of Life Considerations: The patient is keen on preserving his sexual function and current lifestyle, factors that should be considered in the treatment decision.
  • Genetic Counseling: A comprehensive family history is advised for possible BRCA1 and BRCA2 gene mutations.

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