While the sequelae are significant, 30 to 50% of patients treated for prostate cancer could benefit from simple active surveillance. Specialists are mobilizing.
“At 56 years old, following a slightly above average PSA test, I was subjected to 12 prostate biopsies. Result, 1 in 12 samples reveal that I have cancer “, says Jacob, 62. Like him each year, 62,500 men undergo treatment by surgery, chemotherapy and / or radiotherapy according to the Health Insurance. “Without tweezers,” continues this patient, the doctor tells me that it is located at the level of the nerves which allow the erection and that I will keep after-effects. After the consultation, I remained paralyzed in my car for 1 hour, without moving, and from there, my life was turned upside down ”.
Prostate cancer is the most common cancer in 50-year-old men, with 71,200 new cases in 2011 and 8,700 deaths per year. However, some specialists and several studies show (1) that we are currently treating too many patients who do not need to be. “Between 30% to 50% of prostate cancers that are diagnosed have criteria of severity which would justify a simple monitoring”, summarizes Professor François Desgrandchamps, head of the urology department at Saint-Louis hospital (Paris). An attitude that would have serious consequences since the treatments have a strong impact on the quality of life of these men. About 10% of patients have urinary sequelae after surgery. Their sexuality is also profoundly disrupted: after prostate surgery, a third of men would be impotent and 60 to 80% would be impotent after the rays.
Listen to Prof. François Desgrandchamps, head of the urology department at Saint-Louis hospital (Paris): “We must protect these patients from this excessive treatment.”
A screening. Contrary to the recommendations for breast and colon cancer, systematic screening for prostate cancer, by assaying prostate specific antigen (PSA) and / or a rectal examination, is not officially organized. Yet, in fact, it does exist. This has given rise to many controversies for several years. The Haute Autorité de Santé does not recommend it, urologists recommend it, and in the middle, some general practitioners do not always know what position to adopt. It is for this reason that the Practitioner review, a monthly for general practitioners, entrusted to fifteen specialist doctors, the task of carrying out a complete update on the management of prostate cancer which has just been published.
Listen to Dr Amaury De Gouvello, general practitioner : ” We are torn between HAS and urologists. On the one hand, we are afraid of missing out on a very advanced cancer and on the other, there are all its PSAs that must be interpreted. It would help us if they tuned their violins. “
Biopsies. As a result of PSA tests, 91,600 men perform biopsies each year looking for prostate cancer, with a high probability of finding one. Indeed, it is a very common disease, studies show that at age 80, almost 80% of men have cancer cells in their prostate. For most men with this cancer, this cancer does not cause clinical signs or symptoms in their lifetime. And yet, many of them are subjected to heavy treatment with significant repercussions in their daily lives.
Why are we treating too many patients?
The reasons for overtreatment in France are multifactorial. “Some doctors still think that prostate cancer is necessarily an aggressive cancer”, explains Prof. Michael Peyromaure, of the urology department of Cochin hospital. And then there is a pressure of the numbers. The fact of doing a lot of operative acts raises the rankings, increases the prestige of an establishment, creates notoriety for the urologist and even for some in the private sector. Not for everyone of course, but it also simply increases their income, ”adds the specialist.
Listen to Prof. François Desgrandchamps : ” At the word cancer, some doctors may have the same fear as the patients. And then, there are some patients who are afraid, who demand that they be operated on. “
Which patients should not be treated?
Specialists who denounce overtreatment believe that it is time for doctors and patients to have clear information.
“In prostate cancer, there are at least two main types of cancer, dangerous ones and others with very slow progression,” comments Professor François Desgrandchamps. These have specific criteria. These are cancers with PSA below 10. A Gleason score less than or equal to 6. The Gleason score assesses the appearance of cancer under a microscope, and if the cancer is aggressive, this score is higher, at- above 7. ”
In addition, when the number of cancer biopsies is low, this reflects a low tumor volume and therefore a lower risk. Patients with these criteria could therefore have simple regular monitoring as a treatment option. Several studies show, moreover, that in patients monitored for a long time, in the end, only about a third of them need treatment.
What does this active surveillance consist of?
For slow-growing cancers, the idea of offering active surveillance more widely is attracting more and more healthcare professionals. It consists of telling ourselves that we are going to leave the patient alone, that is to say not to operate immediately, and that we will act if the cancer starts to progress. “Active surveillance has many benefits, but in young and anxious patients, in my experience, it can sometimes cause anxiety. Some end up seeing another urologist and having an operation anyway, ”adds Professor Michael Peyromaure.
Listen to Prof. François Desgrandchamps : ” When the cancer is eligible for surveillance, we do PSA every 3 months on the 1sttime year, as well as a follow-up biopsy at one year. “
Despite everything, it seems that the overtreatment of prostate cancer is already on the decline. In recent years, the number of radical prostatectomies has increased from 26,500 in 2007 to 22,000 in 2010. While 10 years ago, few urologists offered this active surveillance, today the Association Française d’Urologie (AFU), which has often been singled out in this area, in particular for its position in favor of annual individual screening between the ages of 50 and 75, is also positioning itself in favor of this alternative. “In 2007, after a PSA at 8 and a prostate biopsy, I learned that I had cancer,” says Francis, 71 years old. I am told that it is a little dangerous cancer and that if I want, we can just watch it for the moment. For me “cancer” meant “operation”, but I trusted my doctor. Today everything is fine, I don’t feel like I’m sick. I do not regret having followed the advice of this surgeon who offered me precisely not to operate, ”
Listen to Dr Patrick Coloby, president of the Association Française d’Urologie: ” A cut-off value of PSA should not trigger biopsies. Maybe that was the attitude at one point. “
(1)
– Active Surveillance for Low-Risk Prostate Cancer Worldwide: The PRIAS Study
– Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement
.
