Using the fortieth anniversary of the discovery of PSA as a starting point, EMUC19 began with a session on early prostate cancer detection. The session immediately demonstrated the multidisciplinary nature of the EMUC scientific programme, drawing on the expertise of urologists, radiation oncologists, radiologists, pathologists, and researchers.
The experts gave their view on the continued use of PSA as a screening tool and the current state (and future potential) of imaging or biomarker-based alternatives.
The 11th edition of the European Multidisciplinary Meeting on Urological Cancers is taking place in Vienna on 15-17 November. It was preceded by the 8th Meeting of the EAU Section of Urological Imaging and other supplementary meetings on the 14th. EMUC19 is a collaboration of the European Society for Medical Oncology (ESMO), the European Society for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).
A case for timely detection
Prof. Chris Bangma (Rotterdam, NL), urologist, co-chaired the session on early detection and the 40 years of PSA. He suggested that the audience use the coffee break after the session to celebrate the milestone. Its discovery in 1979 had a huge impact on the medical profession, patients and governments alike.
As an illustration of how far we’ve come (and perhaps as a warning if PSA testing is recklessly abandoned) Prof. Roobol (Rotterdam, NL) painted a picture of prostate cancer diagnosis and treatment in the 1970s and 80s. Patients were diagnosed at a point where the cancer had spread to bones and only one in 2-3 patients survived. Following a huge rise in PSA testing in the early 2000s, there followed a reflective period and fear of overdiagnosis. “But stopping PSA testing is not the way to go,” warned Roobol, fearing a return to mortality levels of the 1980s.
“We have to preserve the achievements of recent decades and work on preventing the excesses. In two words: Risk Assessment.” Roobol proposed an approach for 2019 and beyond that started with baseline PSA, then risk stratification, imaging, further risk stratification, biopsy, and then treatment (including active surveillance) if required.
Earlier in the session, Prof. Hein Van Poppel lamented the recent decline in PSA screening and the associated increase in mortality in several Western European countries. “This could be prevented with early detection and appropriate treatment.” Van Poppel warned the audience for what he termed “anti-PSA propaganda” and the discouragement of PSA use. He concluded that effective use of supplementary tools and technologies like new biomarkers and MRI can avoid overdiagnosis and overtreatment.
Crucially, Van Poppel argued that Europe’s adult male population “needs to be informed” directly, thereby increasing awareness of PSA testing and the importance of early detection. The EAU is also working in a wider coalition of experts and patient organisations to lobby the European Commission to recommend population-based screening and hopefully change national guidelines. This is part of a longer strategy that was outlined at the EAU’s National Societies Meeting earlier this year and further detailed in an opinion piece on behalf of the EAU.
Van Poppel also hailed EMUC as a major achievement, a real multidisciplinary meeting that reflected the reality that urinary cancers no longer belong to a single specialty.
A voice to be heard
The morning’s session progressed to include the current state and (near-)future potential of various early detection options including MRI (specifically PI-RADS), the grading system used by pathologists, and biomarkers and genomics. A lot of discussions took place in between the talks, covering topics like certification for hypothetical prostate imaging centres, and the role of artificial intelligence in risk stratification.
One discussion focused on the needs of patients and their experiences with their GPs: Dr. Erik Briers (Hasselt, BE) who was in the audience and identified himself as a prostate cancer patient mentioned the “own way of thinking” that general practitioners had when it came to their patients and prostate cancer.
“They feel that they have to protect men from overdiagnosis and overtreatment. But actually, men want to know about their prostate cancer when it is still curable. It might help to adjust the training of GPs, they have to learn that urologists and other disciplines are not out to take our prostates. They want to help us in the best possible way, and our doctors should not be afraid to refer us to a specialist.”