Contrasts in care: Europe finally on board with early detection of prostate cancer
Last chance to sign up for Active Surveillance 101 course on Saturday at ASPI
By Howard Wolinsky
You’d think prostate cancer is a radically different disease in the United States vs. Europe based on the way it is diagnosed and treated.
In the U.S.:
—PSA (prostate-specific antigen) blood testing has been routinely available for many years—though its use has fallen off dramatically because of debates created by guidelines from the U.S. Preventive Services Task Force over the past decade.
—U.S. urologists rely on transrectal biopsies. Only 5% of American urologists use safer transperineal biopsy to avoid potentially sepsis and other infections.
—As of 2021, only 60% of American men with low-risk prostate cancer go on active surveillance, close monitoring of their disease with exams, PSAs, MRIs and biopsies.
—DNA testing for the presence of markers for prostate cancer, such as BRCA 1 and 2 is increasingly common as is genomic testing of prostate cancer tumors.
Now compare with Europe:
—Early detection of prostate cancer was not common in Europe but is now getting a push in Europe. The European Commission has endorsed the concept of early detection for prostate cancer.
In the past, PSA testing was restricted in Europe. Urologist Hendrik Van Poppel, MD, policy chief for the European Association of Urology, told me in a recent interview that this agenda is being pushed hard—with success—in Europe. (I’ll run the interview soon.)
But in the past, doctors were, for example, prohibited by law in Holland from recommending PSA testing. But if a patient asked to be tested, the family doctor could run a test. It was passive detection dependent on patients.
—Active surveillance came to the U.S. and Canada in the late 1990s. It came late to Europe after the turn of the century. But places such as Sweden lead the world with 90%-plus uptake of MS. Holland and the U.K. also have uptake of AS.
—Transperineal biopsies have been the standard of care in Europe since EAU adopted this as policy in January 2021. Van Poppel told me that transrectal biopsies would be considered “medical malpractice” in Europe.
—European doctors, especially in the United Kingdom, have led the way with using MRI testing before doing biopsies. In fact, some urologists are trained to read MRIs. American doctors gradually have come over to an MRI-first approach.
—But European (and also Canadian) doctors, possibly because of funding restrictions from nationally funded health schemes, do not offer DNA testing.
The European Council is recommending expansion of screening for prostate, lung and gastric cancers under the EU Cancer Screening Scheme put forward under Europe's Beating Cancer Plan.
“Focusing on detection of cancers at an early stage, the objective of the proposed recommendation is to increase the number of screenings, covering more target groups and more cancers,” EU Council said in a press release on Sept. 20.
Specifically for prostate cancer, the council recommends testing in men up to age 70 on the basis of prostate-specific antigen testing, and magnetic resonance imaging (MRI) scanning as follow-up.
Vice-President for Promoting European Way of Life, Margaritis Schinas, said: “Cancer is a health priority for us. In the past two years, COVID has taken a toll on cancer prevention, detection, and diagnosis. The sooner cancer is detected, it can make a real difference by increasing treatment options and saving lives. And for this, we need to boost cancer screening across the EU. Today, we again show our commitment to fight cancer decisively and collectively."
This new EU Council said its approachis based on the latest available scientific developments and evidence and will support its member states ensuring that 90% of the EU population who qualify for breast, cervical and colorectal cancer screenings are offered such screening by 2025. The new recommendation also expands population-based organized cancer screening to include lung, prostate and, under certain circumstances, gastric cancers.
Each country will have to adopt the recommendations individually.
Some countries may have difficulty cover the costs because there are wealth gaps in Europe such as low-income Romania, where there are few MRI scanners available, and wealthy Scandinavia, where the expensive MRIs are commonly available.
So good news for European men regarding screening, biopsies and MRIs, but they lag on DNA testing, which is making a difference for American men.
American men have ready access to DNA testing and MRIs but lag woefully behind on transperineal testing. Seems screwed up.
These are my opinions of course. why can’t doctors worldwide convene conferences to harmonize guidelines to find the best practices for all patients in place of this pathwork of practice we now face? Isn’t this the same disease wherever you live despite your health system?
Active Surveillance 101 course launches at ASPI meeting
ASPI will be premiering the first of a new video series named "Active Surveillance 101" at 12-1:30 p.m. Eastern on Saturday, September 24, 2022.
Like 101-level courses in colleges, AS 101 is aimed at teaching the basics. In this case, it's the basics of active surveillance, close monitoring of low- to favorable intermediate-risk prostate cancer.
The program features conversations between actual patients and their partners/spouses and leading experts. The goal of this series is to reach all AS candidates, including those who have not yet been diagnosed with prostate cancer but have rising PSAs (prostate-specific antigen) blood levels and offer them an introduction to AS and help them formulate questions when they go to their family doctors, urologists, or oncologists.
Register here: ASPI SEPTEMBER ZOOM MEETING
The first episode features a couple , Nancy and Larry White in a simulated office visit with Dr. Steve Spann, a top family physician and dean of the University of Houston College of Medicine. They discuss Larry's rising PSA and what it may mean.
In subsequent episodes, the couple visits Dr. Laurence Klotz, of the University of Toronto, the "father of active surveillance." Other episodes of AS 101 are being developed on biopsies, imaging, and DNA testing.
AS 101 is sponsored by the Active Surveillance Coalition, which includes Active Surveillance Patients International, the AnCan Virtual Support Group for Active Surveillance, Prostate Cancer Support Canada, Prostate Cancer Research Institute, and TheActiveSurveillor.com newsletter. We encourage you to share this series with anyone who you know who is dealing with this issue, including your family physician.