Prostate Cancer Nomenclature: Impact on Screening Guidelines "Presentation" - Timothy Wilt
July 24, 2024
At the CAncer or Not Cancer: Evaluating and Reconsidering GG1 prostate cancer (CANCER-GG1?) Symposium, Timothy Wilt discusses the potential impact of changing prostate cancer nomenclature on screening guidelines. Dr. Wilt notes that current screening rates remain high despite limited net benefit. He suggests that changes in clinical practice guidelines may be driven more by advocacy than science.
Biographies:
Timothy Wilt, MD, Professor of Medicine, Core Investigator, University of Minnesota, Minneapolis, MN
Biographies:
Timothy Wilt, MD, Professor of Medicine, Core Investigator, University of Minnesota, Minneapolis, MN
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Read the Full Video Transcript
Timothy Wilt: Hi. Thanks so much. I want to thank everybody for having this meeting and inviting me. What you guys are doing is really good. I'm supposed to talk about whether a change in nomenclature will affect screening guidelines. By way of background, I'm a primary care physician, health services researcher, former US Preventive Services Task Force member, and current chair at the American College of Physicians Clinical Guideline Group.
This is good work. It will reduce harms related to the diagnosis and treatment of prostate cancer, but I don't think that it will change the recommendation because it does nothing to the benefits side of the equation. Multiple randomized controlled trials of screenings have shown at best, when focused on the ERSPC study, a small reduction in prostate cancer mortality through many years, and that's the assessment of the US Preventive Services Task Force. So this won't change that benefit standpoint. If they get to a B recommendation, they need moderate certainty of moderate net benefit, so that means at least moderate benefit, and I don't see that this gets us there.
I would also say in the current paradigm with a C recommendation, screening rates are still quite high, certainly out of proportion with what might be thought of for our net benefit. In the VA, at least more than 50% of men aged 55 to 69 have undergone a PSA at the VA, and it's certainly higher when you look at veterans getting their care elsewhere. I do think there may be changes in the clinical practice guidelines, but I think they'll be driven more by politics and advocacy rather than pure science. There is the upcoming CAP study and the updated results of ProtecT. I'm skeptical that they're going to show widely changing results from what they did previously.
What I've seen now is the role of active surveillance, but I wish there was more of a focus on what the science shows from randomized trials, and we can quibble about the quality of surgery in a PIVOT study. But the results in observation and men diagnosed in the early PSA era with low-risk disease, who certainly had higher risk disease in their prostate biopsies, were outstanding with cancer mortality at 20 years of 5% and an absolute risk difference versus immediate surgery of 1%. It is undoubtedly vastly superior today. Yet clinical practice guidelines do not recommend watchful waiting except for men with a life expectancy of less than five years.
So words matter, changing the nomenclature could matter, but words also matter in what physicians do, what clinical practice guideline members do, and what societies and advocacy members say. My recommendation for future research would be to figure out how clinical practice guidelines can develop recommendations and statements that are consistent with the science of watchful waiting versus early radical treatment, particularly in the PSA era with MRI testing, and how maybe policymakers and payers can implement pay-for-performance measures to improve the health we provide our patients by reducing unnecessary and overtreatment and enhancing the role of watchful waiting in addition to active surveillance. Thank you.
Timothy Wilt: Hi. Thanks so much. I want to thank everybody for having this meeting and inviting me. What you guys are doing is really good. I'm supposed to talk about whether a change in nomenclature will affect screening guidelines. By way of background, I'm a primary care physician, health services researcher, former US Preventive Services Task Force member, and current chair at the American College of Physicians Clinical Guideline Group.
This is good work. It will reduce harms related to the diagnosis and treatment of prostate cancer, but I don't think that it will change the recommendation because it does nothing to the benefits side of the equation. Multiple randomized controlled trials of screenings have shown at best, when focused on the ERSPC study, a small reduction in prostate cancer mortality through many years, and that's the assessment of the US Preventive Services Task Force. So this won't change that benefit standpoint. If they get to a B recommendation, they need moderate certainty of moderate net benefit, so that means at least moderate benefit, and I don't see that this gets us there.
I would also say in the current paradigm with a C recommendation, screening rates are still quite high, certainly out of proportion with what might be thought of for our net benefit. In the VA, at least more than 50% of men aged 55 to 69 have undergone a PSA at the VA, and it's certainly higher when you look at veterans getting their care elsewhere. I do think there may be changes in the clinical practice guidelines, but I think they'll be driven more by politics and advocacy rather than pure science. There is the upcoming CAP study and the updated results of ProtecT. I'm skeptical that they're going to show widely changing results from what they did previously.
What I've seen now is the role of active surveillance, but I wish there was more of a focus on what the science shows from randomized trials, and we can quibble about the quality of surgery in a PIVOT study. But the results in observation and men diagnosed in the early PSA era with low-risk disease, who certainly had higher risk disease in their prostate biopsies, were outstanding with cancer mortality at 20 years of 5% and an absolute risk difference versus immediate surgery of 1%. It is undoubtedly vastly superior today. Yet clinical practice guidelines do not recommend watchful waiting except for men with a life expectancy of less than five years.
So words matter, changing the nomenclature could matter, but words also matter in what physicians do, what clinical practice guideline members do, and what societies and advocacy members say. My recommendation for future research would be to figure out how clinical practice guidelines can develop recommendations and statements that are consistent with the science of watchful waiting versus early radical treatment, particularly in the PSA era with MRI testing, and how maybe policymakers and payers can implement pay-for-performance measures to improve the health we provide our patients by reducing unnecessary and overtreatment and enhancing the role of watchful waiting in addition to active surveillance. Thank you.