Prostate Cancer Treatment on the Basis of an Individual Risk Profile; Can we Reduce Overtreatment?

 Prostate cancer (PCa) is the most prevalent cancer in male population with an incidence rate of 93 per 100.000 men in Europe and is the sixth leading cause of cancer related deaths in men. In the last two decades the incidence of PCa has increased, which is related to widespread prostate-specific antigen (PSA) based screening and increased life expectancy. Mortality rates of prostate cancer have been reduced due to improvement in treatment and/or the widespread screening activities. Major down sides of screening are the potential risks of overdiagnosis and subsequent overtreatment. Approximately 50% of PCa cases detected through screening are potentially overdiagnosed and hence do not require active treatment. However, in clinical practice men with a potentially non-life-threatening cancer (indolent cancer) are often treated actively resulting in unnecessary suffering from serious side effects coinciding with active treatment. The way out of this dilemma is two-fold. First, the actual diagnosis could be delayed or even avoided and second, radical treatment could be delayed or avoided for patients with low-risk PCa. To better predict the presence of a (potentially indolent) prostate cancer nomograms have been developed. These multivariate prediction tools can be of aid in avoiding unnecessary biopsies reducing overdiagnosis, or identifying potentially indolent prostate cancer after diagnosis and hence adapt the treatment strategy. In this expert opinion we discuss the available tools and their performance in reducing the unwanted side effects of prostate cancer screening. In addition, we provide an overview of strategies concerning optimisation and individualisation of treatment, to reduce overtreatment of prostate cancer.