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Adam Kibel: So I don't have many slides. I have probably much stronger opinions or as strong opinions. So I think this is the argument for rebranding. It really boils down to grade group 1 has a low risk of doing harm. I'm a little critical of that because I think that is true for patients that undergo radical prostatectomy, which I agree those patients were overtreated. But there are no patients that have undergone a radical prostatectomy and found truly to have grade group 1 and died of their disease.

But there are plenty of patients that have grade group 1 at biopsy that eventually progressed and end up dying of their cancer, maybe because it was missed, maybe because it progressed. Second thing, which I think we all agree is treatment is bad. And if we can avoid treating patients, that's a win. I think the treatment is bad issue where patients having grade group 1 undergoing radical prostatectomy and radiation is, I'm not saying solely a US problem, but it is a US problem, maybe Canadian as well. And we can't just change the pathology on the basis of what goes on in our country. We have to think, have a worldview, which is why it's so important that people from other parts of the world are actually here.

Active surveillance has been adopted much better in other countries maybe because of the way we're paid. This is the argument of staying the course. The risk is real for many patients. Biopsy incompletely assesses the prostate, diagnostic and treatment paradigms are evolving. We all know that focal therapy is coming into vogue. People are using systemic agents in order to treat patients that have localized prostate cancer. And practically I think the change will either impede management or have no impact. Those are really the two choices. So biology, and I'm not a pathologist, but grade group 1 can be invasive. If there's perineural invasion, there can be extraprostatic extension.

Those are hallmarks of aggressive disease and molecularly grade group 1 has many of the hallmarks of an aggressive disease. PTEN mutations are occurring in these patients. Changes in the nomenclature may encourage pathologists to overgrade. What I mean by that is the pathologist is sitting there saying the patient has grade group 3 to the grade group 1. Maybe they have grade group 2, and if they say it's not cancer and the patient isn't followed up, a pathologist five years later will say, you missed the higher grade cancer. And I think there will be a subtle increase in the number of patients that are called to have a higher grade cancer.

Speaker 2: More than subtle.

Adam Kibel: Say it again.

Speaker 2: More than subtle.

Adam Kibel: Right. I mean, I think it's inevitable. I mean, this is the problem that radiologists have, just think a few seconds. Okay. Other factors beyond grade potentially determine aggressiveness, and calling grade group 1 non-cancer, I think will lead to inconsistency in biopsy reporting. What I mean by that is they have grade group 7 in one place, and 6 in another. What are they? I get in charged time when I can't get into advance.

I got one more slide. Okay. The clinical implications I think are really the strength here. The significant upgrading at the time of surgery. So people who have biopsy grade group 1 don't have clinical grade group 1. Removing the label of cancer may make follow-up challenging. Already 50% of patients fail to follow up. I was talking to Declan about this. It might be higher in other countries. Patients who fail follow-up are 3.5 times more likely to develop mets. That's data from Dr. Klotz here. Will insurers allow the same follow-up? And patients are adopting active surveillance. So in the end, if the follow-up is the same, why are we making the change? And if the follow-up is different, aren't we worried about missing cancer that progresses?