By Howard Wolinsky In August 2010, Mark Scholz, MD, and his patient Ralph Blum sounded the alarm about overdiagnosis and overtreatment of prostate cancer in their expose “Invasion of the Prostate Snatchers.” The Snatchers are still at it. Later that year, their book helped save me from going under the knife when a urologist told me I had
1) Re your citation from Dr. Scholz: "Scholz described a recent European study......." could you provide a link to that study, since most recent studies out of Europe and the U.S. conclude that the combined MRI-Targeted and Fusion/Systematic biopsy is more efficacious than an MRI-Target biopsy alone. The overall estimated false negative rate of mpMRI is around 10–20%. I believe that biopsy is the standard of care at Johns Hopkins with a large AS cohort.
2) Dr. Scholz incorrectly refers to the systematic portion of the combination biopsy as "random." It is not.
I cite it because I think patients would benefit from reading the entire study including the section with the header: Limitations. In that section, the authors state "Our definition of AS is intentionally liberal; follow-up with PSA testing alone without subsequent biopsies is not considered adequate AS but has been documented very commonly in community practice," citing a Michigan study.
4) In your article, you refer to the "Oncotype, Polaris and Decipher" tests. In his January 30 webinar, Dr. Scholz advised patients to avoid the Decipher test.
In my opinion, Dr. Scholz's book was groundbreaking and was instrumental in moving the needle on unnecessary over treatment and towards Active Surveillance. There is no doubt about that. However, now, work needs to be done to bridge the divide in the PCa community, as to how to communicate diagnoses of low to favorable-risk cancer to patients. The premise that there are "more prostate snatchers" out there serves to fan the flames of the divide.
The AUA guidelines for the AS management protocol states "For patients with low-risk prostate cancer, clinicians should recommend active surveillance as the preferred management option. (Strong Recommendation; Evidence Level: Grade A)." However, in that same paragraph: "The Panel nevertheless acknowledges that select patients with low-risk disease may elect definitive local therapy after an informed discussion between clinician and patient. In particular, clinicians may offer immediate treatment to select patients who are fully informed as to all options and risks with low-risk prostate cancer such as those who have a high probability of disease risk reclassification on active surveillance (e.g., high-volume cancer, higher PSA density) or other risk factors for harboring higher-risk disease (e.g., family history of lethal prostate cancer, germline mutation associated with adverse pathology)."
AUA Guidelines: "For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. (Strong Recommendation; Evidence Level: Grade A)"
My point is: I acknowledge, through my own patient advocacy one-on-ones, there are doctors who do not follow the above guidelines. They don't need to; they are not legally binding. However, there are patients who are informed of their options, and select treatment for various reasons. Matthew Cooperberg, MD, in a video with PCRI, tells the story of a patient with low-risk G6 cancer to whom the Dr. recommended the option of Active Surveillance. The patient refused, opting for surgery. While I don't know the entire details of their interaction, Dr. Cooperberg, in the end, states that he performed an RP on the patient as that was his choice.
Perhaps focused efforts should be made to continue to educate both men and doctors, instead of an "us v. them" narrative.
Martin, I am not sure of the citation. I will ask. Howard
Part I:
1) Re your citation from Dr. Scholz: "Scholz described a recent European study......." could you provide a link to that study, since most recent studies out of Europe and the U.S. conclude that the combined MRI-Targeted and Fusion/Systematic biopsy is more efficacious than an MRI-Target biopsy alone. The overall estimated false negative rate of mpMRI is around 10–20%. I believe that biopsy is the standard of care at Johns Hopkins with a large AS cohort.
2) Dr. Scholz incorrectly refers to the systematic portion of the combination biopsy as "random." It is not.
3) You refer to statistics per the AUA Aqua Database. A recent study, among the authors of which are Cooperberg and Catalona can be found here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2801916
I cite it because I think patients would benefit from reading the entire study including the section with the header: Limitations. In that section, the authors state "Our definition of AS is intentionally liberal; follow-up with PSA testing alone without subsequent biopsies is not considered adequate AS but has been documented very commonly in community practice," citing a Michigan study.
4) In your article, you refer to the "Oncotype, Polaris and Decipher" tests. In his January 30 webinar, Dr. Scholz advised patients to avoid the Decipher test.
In my opinion, Dr. Scholz's book was groundbreaking and was instrumental in moving the needle on unnecessary over treatment and towards Active Surveillance. There is no doubt about that. However, now, work needs to be done to bridge the divide in the PCa community, as to how to communicate diagnoses of low to favorable-risk cancer to patients. The premise that there are "more prostate snatchers" out there serves to fan the flames of the divide.
Part 2:
The AUA guidelines for the AS management protocol states "For patients with low-risk prostate cancer, clinicians should recommend active surveillance as the preferred management option. (Strong Recommendation; Evidence Level: Grade A)." However, in that same paragraph: "The Panel nevertheless acknowledges that select patients with low-risk disease may elect definitive local therapy after an informed discussion between clinician and patient. In particular, clinicians may offer immediate treatment to select patients who are fully informed as to all options and risks with low-risk prostate cancer such as those who have a high probability of disease risk reclassification on active surveillance (e.g., high-volume cancer, higher PSA density) or other risk factors for harboring higher-risk disease (e.g., family history of lethal prostate cancer, germline mutation associated with adverse pathology)."
AUA Guidelines: "For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. (Strong Recommendation; Evidence Level: Grade A)"
My point is: I acknowledge, through my own patient advocacy one-on-ones, there are doctors who do not follow the above guidelines. They don't need to; they are not legally binding. However, there are patients who are informed of their options, and select treatment for various reasons. Matthew Cooperberg, MD, in a video with PCRI, tells the story of a patient with low-risk G6 cancer to whom the Dr. recommended the option of Active Surveillance. The patient refused, opting for surgery. While I don't know the entire details of their interaction, Dr. Cooperberg, in the end, states that he performed an RP on the patient as that was his choice.
Perhaps focused efforts should be made to continue to educate both men and doctors, instead of an "us v. them" narrative.