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Reservations about a nomenclature change “Presentation”

Reservations about a nomenclature change “Presentation”

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Adam Kibel: So I don’t have a lot of slides. I probably have much stronger opinions or equally strong opinions. So I think that’s the argument for rebranding. It really comes down to grade group 1 having a low risk of harm. I’m a little critical of that because I think that’s true for patients who have radical prostatectomy, and I agree that those patients are overtreated. But there are no patients who have had radical prostatectomy and were actually grade group 1 and died from their disease.

But there are plenty of patients who have a grade 1 biopsy that has progressed and has ultimately died from their cancer, maybe because it was missed, maybe because it has progressed. Secondly, what we all agree on, is the treatment is bad. And if we don’t have to treat patients, that’s a victory. I think the treatment is a bad problem, where patients with grade 1 who have radical prostatectomy and radiation, I’m not just saying an American problem, but it’s an American problem, maybe a Canadian problem. And we can’t just change the pathology based on what’s happening in our country. We have to think, we have to have a worldview, and that’s why it’s so important for people from other parts of the world to actually be here.

Active surveillance has been much better adopted in other countries, perhaps because of the way we get paid. That’s the argument for staying the course. The risk is real for many patients. Biopsy doesn’t assess the prostate completely, diagnostic and treatment paradigms are evolving. We all know that focal therapy is coming into vogue. People are using systemic agents to treat patients with localized prostate cancer. And in practice, I think the change is either going to hinder management or it’s not going to have an impact. Those are really the two choices. So biology, and I’m not a pathologist, but grade 1 can be invasive. If there’s perineural invasion, there can be extraprostatic extension.

These are hallmarks of aggressive disease, and molecularly, group 1 has many of the hallmarks of aggressive disease. PTEN mutations occur in these patients. Changes in nomenclature can encourage pathologists to overgrade. What I mean by that is, the pathologist sits there and says, this patient is group 3 versus group 1. Maybe they have group 2, and if they say it’s not cancer and the patient is not followed, five years later a pathologist will say, you missed the higher-grade cancer. And I think there will be a subtle increase in the number of patients who are called for 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 about it for a second. Okay. Other factors than grade determine potentially aggressiveness, and calling grade group 1 non-cancerous, I think, is going to 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 those? I get in charge time if I can’t get in early.

I have one more slide. Okay. The clinical implications are really the power here, to me. The significant upgrading at the time of surgery. So people with biopsy grade group 1 do not have clinical grade group 1. Removing the cancer label can make follow-up challenging. 50% of patients already fail follow-up. I talked to Declan about this. It may be higher in other countries. Patients who fail follow-up are 3.5 times more likely to develop metastases. That’s Dr. Klotz’s data here. Will insurers allow the same follow-up? And patients are on active surveillance. So if the follow-up is ultimately the same, why are we making the change? And if the follow-up is different, aren’t we worried about missing cancer that develops?