The Challenge for Urologists Is to Screen, Detect, and Treat Prostate Cancer “Smarter”: Will Ablative Technology Result in Smarter Treatment?

Abstract

Since the mid-1990s, there has been a progressive decline in prostate cancer (PCa) mortality, attributed primarily to prostate-specific antigen (PSA) screening. Despite the 40% decline in PCa mortality, the urology community has been indicted for overscreening, overdetecting, and overtreating PCa. In 2012, theUSPreventative Service Task Force (USPSTF) concluded that the harms of PCa screening outweighed its benefits for allmen and recommended against PSA screening [1]. It is incomprehensible that PSA screening should be summarily abandoned; however, it is imperative that the urology community reassess the paradigm of subjecting all men with ‘‘elevated’’ PSA to a random transrectal ultrasound–guided biopsy and recommending whole-gland treatment (radical prostatectomy [RP] or radiation therapy [RT]) independent of disease aggressiveness. In short, we need to screen and diagnose ‘‘smarter,’’ so we can treat smarter. I have adopted multiparametric magnetic resonance imaging (MRI) [2] and the 4Kscore [3] to decrease unnecessary biopsies due to the poor specificity of PSA screening. I have also adopted MRI/ultrasound-fusion targeted biopsy to decrease overdetection of low-risk disease and underdetection of aggressive disease attributable to random biopsy [4]. The next challenge is to treat smarter. In this month’s issue of European Urology, Chin et al [5] presented results of a prospective phase 1 clinical trial of MRI-guided transurethral ultrasound ablation (MRI-TULSA) of prostate tissue in men with localized PCa. The question is whether whole-gland MRI-TULSA will allow urologists to treat smarter. The application of high-intensity focused