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Q7. Adjust Screening Thresholds Based on Treatment Strategy?

Deferring side effects of treatment are a benefit of delay.
Treatment strategies with active surveillance if appropriate and possibly focal therapy reduce risk of side effects.
Reduced risk of side effects can decrease your threshold for biopsy, possible MRI and other screening actions.

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Biopsy and Treatment Risk Assessment Adjustments

How might you adjust screening thresholds for active surveillance or possibly focal therapy and also for biopsy consequences?

Personal risk assessment for the if-cancer case (from Q1) compares biopsy now and delayed by balancing the consequences of diagnosis and possible treatment side effects with potential loss of life expectancy. See below.
Consideration of the consequences of a biopsy to find prostate cancer including discomfort and the risk of potentially life-threatening sepsis (infection) increases the benefit of delay and the corresponding threshold for biopsy.
Consideration of the reduced consequences of 1) active surveillance rather than primary treatment or 2) focal therapy decreases the benefit of delay and the corresponding threshold for biopsy.
- See Active Surveillance to learn more
- See Focal Therapy to learn more
The consequences of a 1) biopsy and 2) active surveillance or focal therapy are offsetting often with a small net increase because the biopsy increase exceeds the active surveillance or focal therapy decrease.

Therefore, we suggest skipping these adjustments unless you are very interested in the risk assessment adjustment process and are determined to fine-tune your assessment. To learn more, continue to read below or see our free Sample Report.

Personal Risk Assessment for the If-Cancer Case

Question 1. Biopsy Now or Delay Informed by Analysis? explored the consequences of biopsy delay and process for balancing them. See Q1. Biopsy Delay.
Highlights are presented below for convenience.

Consider Consequences of Biopsy, Diagnosis and Treatment

A biopsy of the prostate is the pivotal cancer screening step. It is needed to diagnose cancer that can lead to treatment with possible life saving benefits. However, most prostate cancers are not very life threatening with little or no benefit of treatment.

A biopsy also has negative consequences, including:

Discomfort and the risk of potentially life-threatening sepsis (infection).
Emotional costs that accompany a possible diagnosis of cancer.
Potential side effects of treatment if warranted, such as impotence and incontinence.

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Consider Average Outcomes for a Delayed Biopsy

The bullets show average reductions in life expectancy from a 1-year delay in biopsy, possible diagnosis and treatment if warranted both: 1) Overall and 2) If-cancer is found for the estimated probability a biopsy will find cancer:

0.01-year overall reduction in life expectancy from delay
79% probability a biopsy will not find cancer
21% probability a biopsy will find cancer
0.07-year if-cancer reduction in life expectancy from delay

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CAUTION: These are estimated reductions in life expectancy from delay based on the example cancer growth rate. They are in addition to any decreases in life expectancy from prostate cancer that is diagnosed now with treatment that may not be successful.

Assess Personal Risks for "If-Cancer" Case

Your biopsy timing decision should be based on your assessment of risks. The decision is very personal with wide variation among men and among physicians with potentially large differences between men and their physicians. For example,

Some urologists might be more concerned about the dangers of cancer while
Some primary care physicians might be more concerned about the side effects of biopsy, emotional costs of diagnosis and side effects of treatment.

Different men seem to have highly divergent assessments of the risk tradeoffs.

On the Right: Diagnosis and Treatment Deferral Benefit for the "If-Cancer" Case:

Some men might wait for a 1.0-year “if-cancer” reduction in life expectancy:
- They place a high value on their currently high quality of life that would be disrupted by diagnosis and treatment if warranted and
- Are much less concerned about losing life expectancy toward the end of life when they expect their quality of life may be low.
Other men might only wait for a 0.25-year “if-cancer” reduction in life expectancy:
- They are less concerned about disruption of their current quality of life from diagnosis and treatment if warranted and
- Are more concerned about losing life expectancy, perhaps because they want to see their grandchildren grow up or live as long-as their spouse.

For reference, example if-cancer reduction for a delayed biopsy is:

0.07-year if-cancer reduction in life expectancy from delay

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Biopsy Risk Assessment Adjustment

Highlights of the Example case in Appendix B of our free Sample Report are presented below.
Deferring the discomfort of a biopsy and the risk of potentially life-threatening sepsis (infection) is the additional benefit of a 1-year delay:

4.8 biopsies are needed for each diagnosis in the Example case
10% benefit benefit of biopsy delay as a percentage of diagnosis and treatment is based on an assessment that the consequences of diagnosis and treatment are 10 times greater than a biopsy.
148% probability adjusted for biopsy benefit percentage for biopsy delay.
0.5 year benefit of delay of diagnosis and treatment assessment.
0.74 year adjusted benefit of delay of diagnosis and treatment

In the Example, the benefit of delay increased by 48% when biopsy consequences were considered.

Treatment Risk Assessment Adjustment

There is a chance that the prostate cancer found by biopsy is indolent and suitable for active surveillance rather than primary treatment (surgery or radiation). Active surveillance is increasingly used because it reduces the side effects of treatment. If you plan active surveillance of indolent cancer if diagnosed then you should consider reducing the diagnosis and treatment deferral benefit somewhat.

Focal therapy is a new family of treatments with reduced side effects that try to destroy tumors with little or no damage to the surrounding prostate tissue. Long term effectiveness of focal therapy has not been proven. Reduce your biopsy threshold further if you plan focal therapy for appropriate cancers.

Highlights of the Example case in Appendix B of our free Sample Report are presented below.

70% of the consequences of diagnosis and treatment are treatment side effects.
25% of the diagnoses in the Example are appropriate candidates for active surveillance.
35% side effects if active surveillance with annual or frequent biopsies is 35% as concerning as primary treatment (surgery or radiation)
89% probability adjusted benefit of delay risk percentage.
0.5 year benefit of delay of diagnosis and treatment assessment.
0.44 year adjusted for surveillance benefit of delay of diagnosis and treatment.

In the Example, the benefit of delay decreased by 11% when active surveillance consequences were considered.

Net Adjusted Benefit of Delay

For the Example, there was a net increase in probability adjusted benefit of delay risk percentage:

100% benefit percentage for diagnosis and treatment before adjustment.
131% probability adjusted benefit percentage for diagnosis and treatment.

For the Example, there was a corresponding net increase in the benefit of delay:

0.5 year benefit of delay of diagnosis and treatment before adjustment.
0.65 year net probability adjusted benefit of delay of diagnosis and treatment.

When done with Question 7, continue to Q8. Collaborative Team

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