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Thread: (C) Screening – Diagnosis – PSA – Imaging – Biopsies

  1. #141
    Impact of biopsy perineural invasion on the outcomes of patients who underwent radical prostatectomy: a systematic review and meta-analysis
    [2019, Review]

    Impact of biopsy perineural invasion on the outcomes of patients who underwent radical prostatectomy: a systematic review and meta-analysis


    Objectives: To investigate the association between biopsy perineural invasion (PNI) and oncological outcomes of prostate cancer (PCa) after radical prostatectomy (RP).

    Materials and methods: A systematic literature search was performed using PubMed, EMBASE and Web of Science up to December 2018 to identify the eligible studies that included localized PCa patients who underwent biopsy and subsequently RP as well as follow-up information. Meta-analyses were conducted using available hazard ratios (HRs) of biopsy PNI from both univariate and multivariate analyses.

    Results: Eighteen studies including 14,855 patients with treatment follow-up information were included in the current systematic review. The rate of biopsy PNI varied between 7.0% and 33.0%. Seven out of the 18 studies that demonstrated biopsy PNI were associated with adverse pathologic features. Thirteen out of the 18 studies showed biopsy PNI correlated significantly with higher rates of biochemical recurrence (BCR)/cancer progression status or worse prognostic outcomes. With pooled data based on four studies with available univariate analysis results and four studies with multivariate analysis, statistically significant associations were found between biopsy PNI and BCR with univariate analysis (HR = 2.05; 95% CI = 1.57–2.68; p < 0.001) and with multivariate analysis (HR = 1.57; 95% CI = 1.28–1.93; p < 0.001).

    Conclusion: Evidence from the included observational studies indicated that biopsy PNI was not only correlated with adverse pathologic characteristics but also with worse BCR prognosis of local PCa after RP. The status of biopsy PNI could serve as a promising risk-stratification factor to help the decision-making process, considering active surveillance (AS) or further treatment for PCa patients.
    [Emphasis mine]

    (Note that the study was on biopsy PNI. PNI is found somewhere in the whole prostate after RP in as much as >80% of cases.)

  2. #142
    Research landscape of liquid biopsies in prostate cancer
    [2019, Review, Full Text]



    Studies show that liquid biopsies are efficient in the detection of circulating cancer products. However, scientific community has not yet implemented this technology in routine clinical practice. Liquid biopsies are less invasive than traditional surgical ones because they rely on the detection of specific biomarkers in readily accessible body fluid samples. The clinical management of prostate cancer depends on the controversial blood serum biomarker PSA (prostate specific antigen). PSA tests have a low accuracy. In addition, a positive PSA result for prostate cancer needs a confirmation through a tissue biopsy. Thus, liquid biopsies are considered tools to find a surrogate biomarker. This review aimed to show the landscape of liquid biopsies in prostate cancer research to understand its challenges and foresee the trends in this area. We performed an exhaustive Pubmed search of articles reporting the study of liquid biopsies in prostate cancer with circulating tumor cells, cell-free nucleic acids and extracellular vesicles as targets. After a thorough analysis, we retrieved sixty-two relevant articles. Among the identified articles, the most used target and body fluid were circulating tumor cells and blood, respectively. Enumeration of circulating tumor cells was the most reported parameter, but it was often combined with other biomarkers. The most used methods for biomarker detection were those based on transcriptome analysis. Despite the vast literature about liquid biopsy in prostate cancer, most studies seem to be stuck on improving the yield of technologies. Consequently, they seem to test a limited number of samples. Larger cohorts could provide robust evidence to translate liquid biopsies of prostate cancer to the clinics.

  3. #143
    Prostate Volume Index Is Able to Differentiate between Prostatic Chronic Inflammation and Prostate Cancer in Patients with Normal Digital Rectal Examination and Prostate-Specific Antigen Values <10 ng/mL: Results of 564 Biopsy Naοve Cases



    To assess the association of prostate volume index (PVI), defined as the ratio of the central transition zone volume to the peripheral zone volume, and prostatic chronic inflammation (PCI) as predictors of prostate cancer (PCA) risk in patients presenting with normal digital rectal exam and prostate-specific antigen (PSA) ≤10 ng/mL at baseline random biopsies.

    We evaluated patients with a negative digital rectal examination (DRE) and a PSA ≤10 ng/mL who underwent initial baseline prostate biopsy from 2010 to 2017. Parameters evaluated included age, PSA, total prostate volume (TPV), PSA density (PSAD), PVI and PCI. All patients underwent 14 core trans-perineal standard biopsies. The association of factors with the risk of PCA was evaluated by logistic regression analysis, utilizing 2 multivariate models: model I included age, TPV, PVI and PCI; model II included age, PSAD, PVI and PC.

    Overall, 564 Caucasian patients were included. PCA and PCI were detected in 242 (42.9%) and 129 (22.9%) cases respectively. In patients with PCA, the median PVI was 0.83 (interquartile range [IQR] 0.62-1.04). In patients with PCI, the median PVI was 1.12 (IQR 0.81-1.47). In model I, age (OR 1.080) TPV (OR 0.961), PVI (OR 0.517) and PCI (OR 0.249) were associated with PCA risk. In model II, the age (OR 1.074), PSAD (OR 3.080), PVI (OR 0.361) and PCI (OR 0.221) were associated with PCA risk.

    Higher PVI and PCI predicted decreased PCA risk in patients presenting with normal DRE, and a PSA ≤10ng/mL at baseline random biopsy. In this subset of patients, PVI is able to differentiate patients with PCI or PCA.
    [Emphasis mine]

  4. #144
    A review of optimal prostate biopsy: indications and techniques
    [2019, Review, Full Text]



    Prostate biopsy is the gold standard diagnostic technique for the detection of prostate cancer. Patient selection for prostate biopsy is complex and is influenced by emerging use of prebiopsy imaging. The introduction of the magnetic resonance imaging (MRI)–transrectal ultrasound (TRUS) fusion prostate biopsy has clear advantages over the historical standard of care. There are several biopsy techniques currently utilized with unique advantages and disadvantages. We review and summarize the current body of literature pertaining to when and how a prostate biopsy should be performed. We discuss current recommendations regarding patient selection for biopsy and discuss future directions regarding prebiopsy imaging. We offer a description of the MRI–TRUS fusion biopsy technique and a comparison of many of the currently available fusion software platforms. Articles pertaining to the title were obtained via PubMed index search with relevant keywords supplemented with personal collection of related publications. Prostate biopsy should be considered for patients with gross digital rectal exam (DRE) abnormality, patients with a prostate-specific antigen (PSA) greater than 4 ng/ml, and concomitant risk factors for prostate cancer or patients with lesions identified on multiparametric MRI (mpMRI) with Prostate Imaging Reporting and Data System 2 (PI-RADS2) score of 4 or 5. MRI–TRUS fusion biopsy has demonstrated advantages in cancer detection when compared with TRUS-guided biopsy. There are currently several fusion software platforms available with a variety of biopsy approaches. Future efforts should detail the role of prebiopsy imaging as a triage tool for prostate biopsy. Consensus should be sought regarding the preferred modality of fusion biopsy. Additional data describing each fusion software platform would enable a more rigorous comparison of platform sensitivities.
    (See Full Text.)

  5. #145
    The prognostic impact of downgrading and upgrading from biopsy to radical prostatectomy among men with Gleason score 7 prostate cancer
    . [2019]

    A Korean study



    Recently, a new prostate cancer (PC) grading system was introduced, where Gleason score (GS) 7 was divided into 3 + 4 = 7 and 4 + 3 = 7 due to the different prognoses associated with each tumor type. However, whether downgrading or upgrading from needle biopsy (NB) to radical prostatectomy (RP) affects oncologic outcomes is currently unknown. Herein, we investigated the prognostic impact of downgrading and upgrading from NB to RP among men with GS 7 PC.

    We retrospectively reviewed the medical records of 3003 patients with localized PC who underwent RP between 2005 and 2014. We included 692 patients with GS 7 PC on both NB and RP specimens. We analyzed the data using Kaplan-Meier methods and Cox proportional hazard models.

    Of the 692 patients enrolled in this study, 389 (56.2%) and 303 (43.8%) patients had RP GS 3 + 4 = 7 and RP GS 4 + 3 = 7 PC, respectively. On the basis of NB and RP GS, 264 (38.1%), 125 (18.1%), 142 (20.5%), and 161 (23.3%) patients were classified as 3 + 4/3 + 4, 4 + 3/3 + 4, 3 + 4/4 + 3, and 4 + 3/4 + 3, respectively. Kaplan-Meier curves showed significant differences in biochemical recurrence (BCR)-free survival across the groups (P < .001). In the multivariate analyses, these groups were significantly associated with BCR (4 + 3/3 + 4: hazard ratio [HR], 1.675; 3 + 4/4 + 3: HR, 1.908; and 4 + 3/4 + 3: HR, 2.699).

    Downgrading and upgrading from NB to RP was an independent predictor of BCR in men with GS 7 PC, which could be due to the amount of Gleason pattern 4.

  6. #146
    Liquid Biopsy in Oligometastatic Prostate Cancer—A Biologist's Point of View
    [2019, Review, Full Text]



    Prostate cancer (PCa) is the main cause of cancer-related mortality in males and the diagnosis, treatment, and care of these patients places a great burden on healthcare systems globally. Clinically, PCa is highly heterogeneous, ranging from indolent tumors to highly aggressive disease. In many cases treatment-generally either radiotherapy (RT) or surgery-can be curative. Several key genetic and demographic factors such as age, family history, genetic susceptibility, and race are associated with a high incidence of PCa. While our understanding of PCa, which is mainly based on the tools of molecular biology-has improved dramatically in recent years, efforts to better understand this complex disease have led to the identification of a new type of PCa-oligometastatic PCa. Oligometastatic disease should be considered an individual, heterogeneous entity with distinct metastatic phenotypes and, consequently, wide prognostic variability. In general, patients with oligometastatic disease typically present less biologically aggressive tumors whose metastatic potential is more limited and which are slow-growing. These patients are good candidates for more aggressive treatment approaches. The main aim of the presented review was to evaluate the utility of liquid biopsy for diagnostic purposes in PCa and for use in monitoring disease progression and treatment response, particularly in patients with oligometastatic PCa. Liquid biopsies offer a rapid, non-invasive approach whose use t is expected to play an important role in routine clinical practice to benefit patients. However, more research is needed to resolve the many existing discrepancies with regard to the definition and isolation method for specific biomarkers, as well as the need to determine the most appropriate markers. Consequently, the current priority in this field is to standardize liquid biopsy-based techniques. This review will help to improve understanding of the biology of PCa, particularly the recently defined condition known as "oligometastatic PCa". The presented review of the body of evidence suggests that additional research in molecular biology may help to establish novel treatments for oligometastatic PCa. In the near future, the treatment of PCa will require an interdisciplinary approach involving active cooperation among clinicians, physicians, and biologists.

  7. #147
    Diagnostic Accuracy of Multiparametric MRI versus 68Ga-PSMA-11 PET/MRI for Extracapsular Extension and Seminal Vesicle Invasion in Patients with Prostate Cancer



    While overall diagnostic performance in local staging of patients with prostate cancer at intermediate to high risk was similar, use of a gallium 68 (68Ga)-labeled Glu-urea-Lys (Ahx)-HBED-CC ligand targeting the prostate-specific membrane antigen (PSMA) (68Ga-PSMA-11) PET/MRI may improve the sensitivity of multiparametric MRI for the detection of extracapsular disease, at the cost of a slightly reduced specificity.

    Recent studies have reported the additive value of combined gallium 68 (68Ga)-labeled Glu-urea-Lys (Ahx)-HBED-CC ligand targeting the prostate-specific membrane antigen (PSMA) (hereafter called 68Ga-PSMA-11) PET/MRI for the detection and localization of primary prostate cancer compared with multiparametric MRI.

    To compare the diagnostic accuracy and interrater agreement of multiparametric MRI and 68Ga-PSMA-11 PET/MRI for the detection of extracapsular extension (ECE) and seminal vesicle infiltration (SVI) in patients with prostate cancer.

    Materials and Methods
    Retrospective analysis of 40 consecutive men who underwent multiparametric MRI and 68Ga-PSMA-11 PET/MRI within 6 months for suspected prostate cancer followed by radical prostatectomy between April 2016 and July 2018. Four readers blinded to clinical and histopathologic findings rated the probability of ECE and SVI at multiparametric MRI and PET/MRI by using a five-point Likert-type scale. The prostatectomy specimen served as the reference standard. Accuracy was assessed with a multireader multicase analysis and by calculating reader-average areas under the receiver operating characteristics curve (AUCs), sensitivity, and specificity for ordinal and dichotomized data in a region-specific and patient-specific approach. Interrater agreement was assessed with the Fleiss multirater κ.

    For multiparametric MRI versus PET/MRI in ECE detection, respectively, AUC, sensitivity, and specificity in the region-specific analysis were 0.67 and 0.75 (P = .07), 28% (21 of 76) and 47% (36 of 76) (P = .09), and 94% (529 of 564) and 90% (509 of 564) (P = .007). For the patient-specific analysis, AUC, sensitivity, and specificity were 0.66 and 0.73 (P = .19), 46% (22 of 48 ) and 69% (33 of 48 ) (P = .04), and 75% (84 of 112) and 67% (75 of 112) (P = .19), respectively. For multiparametric MRI versus PET/MRI in SVI detection, respectively, AUC, sensitivity, and specificity of the region-specific analysis were 0.66 and 0.74 (P = .21), 35% (seven of 20) and 50% (10 of 20) (P = .25), and 98% (295 of 300) and 94% (282 of 300) (P < .001). For the patient-specific analysis, AUC, sensitivity, and specificity were 0.65 and 0.79 (P = .25), 35% (seven of 20) and 55% (11 of 20) (P = .20), and 98% (137 of 140) and 94% (131 of 140) (P = .07), respectively. Interrater reliability for multiparametric MRI versus PET/MRI did not differ for ECE (κ, 0.46 vs 0.40; P = .24) and SVI (κ, 0.23 vs 0.33; P = .39).

    Our results suggest that gallium 68 (68Ga)-labeled Glu-urea-Lys (Ahx)-HBED-CC ligand targeting the prostate-specific membrane antigen (PSMA) (68Ga-PSMA-11) PET/MRI and multiparametric MRI perform similarly for local staging of prostate cancer in patients with intermediate-to-high-risk prostate cancer. The increased sensitivity of 68Ga-PSMA-11 PET/MRI for the detection of extracapsular disease comes at the cost of a slightly reduced specificity.
    [Emphasis mine]

  8. #148
    Optimising the number of cores for magnetic resonance imaging‐guided targeted and systematic transperineal prostate biopsy



    To assess cancer detection rates of different target‐dependent transperineal magnetic resonance (MR)/ultrasonography (US) fusion‐guided biopsy templates with reduced number of systematic cores.

    Patients and Methods
    Single‐centre outcome of transperineal MR/US fusion‐guided biopsies of 487 men with a single target MR imaging (MRI) lesion, prospectively collected between 2012 and 2016. All men underwent transperineal targeted biopsy (TB) with two cores, followed by 18–24 systematic sector biopsies (SB) using the Ginsburg protocol. Gleason score ≥7 prostate cancer detection rates for two‐core TB, four‐core extended TB (eTB), 10‐ to 20‐core saturation TB (sTB) including cores from sectors adjacent to the target, and 14 core ipsilateral TB (iTB) were compared to combined TB+SB.

    Cancer was detected in 345 men and Gleason score 7–10 cancer in 211 men. TB alone detected 67%, eTB 76%, sTB 91% and iTB 91% of these Gleason score 7–10 cancers. In the subgroup of 33 men (7% of cohort) with an anterior >0.5 mL highly suspicious MRI lesion and a prostate volume ≤45 mL, four‐core eTB detected 31 of 32 cancers (97%) and all 26 Gleason score 7–10 cancers.

    sTB detected Gleason score 7–10 cancer in 25% more of the men than a two‐core TB approach, and in almost as many men (91%) as the 20–26‐core combined TB+SB, while needing only 10–20 cores. A four‐core extended TB may suffice for large, highly suspicious anterior lesions in small or slightly enlarged prostates.

  9. #149
    Targeted biopsy of the prostate: does this result in improvement in detection of high‐grade cancer or the occurrence of the Will Rogers phenomenon?



    To investigate whether patients with Gleason 3 + 4 cancer on transrectal biopsy are upgraded after undergoing transperineal magnetic resonance imaging (MRI)‐targeted biopsy and whether this has implications for current clinical practice.

    Patients and Methods
    In this retrospective analysis we examined 107 consecutive patients presenting at a single tertiary referral centre (July 2012 to July 2016) with prostate cancer of Gleason score 3 + 4 on transrectal ultrasonography (TRUS)‐guided systematic non‐targeted biopsy who then underwent a multiparametric MRI followed by MRI‐targeted transperineal prostate biopsy for accurate risk stratification and localization.

    The patients’ mean (sd) age was 67.0 (8.0) years, and they had a median (interquartile range) PSA concentration of 6.2 (4.7–9.6) ng/mL. Of the 107 patients, 84 (78.5%) had Gleason 3 + 4 on both transrectal systematic biopsy and transperineal MRI‐targeted biopsy. Nineteen patients (17.8%) were upgraded to Gleason 4 + 3, three patients (3.0%) to Gleason 4 + 4 and one patient (1.0%) to Gleason 4 + 5. These differences were significant (P = 0.0006). Likewise, 23/107 patients (22%) had higher‐risk disease based on their targeted biopsies.

    The use of targeted biopsy in men with impalpable cancer, ultimately upgraded one in five patients from favourable‐intermediate‐ to unfavourable‐intermediate‐risk disease or worse. This has significant clinical implications for men considering active surveillance or radical treatment. Our risk calculators must now be validated using these data from targeted biopsy as the technique becomes widely adopted.

    The Will Rogers phenomenon in urological oncology [2008]



    Improvement in the prognosis of patient groups due to stage or grade reclassification is called the Will Rogers phenomenon. We determined the significance of the Will Rogers phenomenon in urological oncology.

    Studies referring to the Will Rogers phenomenon in urological oncology were identified through a MEDLINE search. Samples of articles not referring to the phenomenon directly but likely to be biased by it, such as articles comparing contemporary data to historical controls, were also reviewed.

    In prostate cancer the Will Rogers phenomenon is the result of the late 1990s acceptance that Gleason scores 2 to 4 should not be assigned on prostate biopsy. Consequently grade inflation occurred and current readings are almost 1 Gleason grade higher compared to past readings of the same biopsy. The result is an illusion of improvement in grade adjusted prognosis. In bladder cancer the Will Rogers phenomenon arises from improvement in histopathological processing of cystectomy specimens enabling the identification of microscopic perivesical fat infiltration and lymph node metastases not recognized in the past. Up staging from pT2 to pT3 and N0 to N+ may partly explain the improved stage adjusted survival after radical cystectomy observed in contemporary series. The Will Rogers phenomenon may also explain the correlation between the total number of lymph nodes removed at radical cystectomy and survival. As more lymph nodes are removed the probability of identifying metastases and up staging to N+ increases.

    Comparison of contemporary results to historical controls may be biased by the Will Rogers phenomenon. Ignoring the possibility of stage or grade reclassification may lead to erroneous conclusions.
    [Emphasis mine]

    Prostate Cancer and the Will Rogers Phenomenon [2005, Full Text]

    An equally important but subtler bias that may also be operating to improve apparent prostate cancer outcomes is the Will Rogers phenomenon (18 ) . This term was coined by Feinstein et al. (18 ) , who often quoted a Will Rogers joke that “when the Okies moved to California, the IQ of both states went up.” This phenomenon can occur when patients are reclassified, as often happens after the introduction of more sensitive staging tools or changes in classification systems. In their original description of the phenomenon, Feinstein et al. focused on stage migration among men with newly diagnosed lung cancer. The phenomenon, however, can occur whenever patients are reclassified—as seen, for example, in the changes in stage-specific survival after the adoption of the 2003 American Joint Committee on staging recommendations for breast cancer (19) .
    Last edited by DjinTonic; 09-11-2019 at 01:31 PM.

  10. #150
    ‘Feelings, and feelings, and feelings. Let me try thinking instead’: Screening for distress and referral to psychosocial care for men with prostate cancer
    [2019, Editorial]


    In 1961, CS Lewis observed that grief felt like fear, or being concussed, with ‘an invisible blanket between the world and me’ (Lewis, 1961). During his exploration of grief, Lewis observes that from feelings one can move to thinking, that is, to apply the rational self as a point from which to move forward. And so to prostate cancer.

    The global burden of prostate cancer is escalating with over 1.2 million men diagnosed each year (Bray et al., 2018 ). The face of prostate cancer has changed over the past three decades since the advent of the prostate‐specific antigen test and the promise of early detection and cure (Schrφder, Hugosson, Carlsson, et al., 2012; Schrφder, Hugosson, Roobol, et al., 2012), and new approaches to the treatment of advanced disease (Emmett et al., 2017). Clinical research and technological advances have expanded treatment possibilities for these men—theranostics and personalised medicine offer new hope (Huey, Hawk, & Offodile, 2019). However, the personal experience of prostate cancer and the feelings that surround prostate cancer are connected to physical, social, psychological and relationship challenges that for many men will be long term, if not lifelong (Chambers, Ng, et al., 2017; Chambers, Occhipinti, et al., 2019). The data are clear. After diagnosis, up to one in four men experience anxiety and up to one in five report depression (Watts et al., 2015). Heightened distress occurs across all treatment approaches, exacerbated when disease or symptom effects are advanced (Chambers, Ng, et al., 2017; Coughlin et al., 2018; Meissner, Herkommer, Marten‐Mittag, Gschwend, & Dinkel, 2017). Risk of suicide is increased after a diagnosis of prostate cancer in comparison with controls (Bill‐Axelson et al., 2010; Carlsson et al., 2013; Dalela et al., 2016), particularly in the first 6–12 months after diagnosis (Guo et al., 2018; Smith et al., 2018 ). Unmet needs for support for psychological care are widely prevalent (Hyde et al., 2017; Smith et al., 2007). For many, the diagnosis of prostate cancer will generate strong feelings and a life permanently changed.

    And so to thinking, to act.

    Brief distress screening for people with cancer is an accepted standard in oncology care (Holland, Watson, & Dunn, 2011); it is well validated in men with prostate cancer (Chambers, Zajdlewicz, Youlden, Holland, & Dunn, 2014); and evidence‐based and accessible psychosocial interventions have been developed (Chambers, Hyde, et al., 2017; Crawford‐Williams et al., 2018 ). Psychosocial care is at the core of best practice survivorship care (Andersen et al., 2014). Unless men experiencing high levels of distress are identified within the care pathway, and referred for intervention or support, they are unlikely to receive the care they need (Chambers & Heathcote, 2018 ). To date, in Australia and likely elsewhere, distress screening for men with prostate cancer has not been universally implemented and so, many men will have their psychological needs left both unnoticed and unaddressed. By and large, psycho‐oncology research has not addressed implementation and systems‐based interventions that focus on sustainable improvements in psychosocial care are scant (Sanson‐Fisher et al., 2019). Consonant with this, for men with prostate cancer and their partners, psychosocial and survivorship care implementation studies are largely absent (Chambers, Hyde, et al., 2017; Crawford‐Williams et al., 2018 ). Herein lies the problem.

    The Prostate Cancer Foundation of Australia and Australian National Health and Medical Research Council Centre for Research Excellence in Prostate Cancer Survivorship partnered with key Australian medical, nursing and research leaders to develop a position statement on screening for distress and on providing psychosocial care for men with prostate cancer (available at https://www.pcfa.org.au/). The statement was launched on 11 September 2019 in Canberra to encourage and guide advocacy to enhance psychosocial outcomes for men and their families as well as cancer survivorship more broadly. Importantly, the statement is endorsed by the Urological Society of Australia and New Zealand; Australia and New Zealand Urological Nursing Society; Royal Australian and New Zealand College of Radiologists; Medical Oncology Group of Australia; Australia and New Zealand Urogenital and Prostate Cancer Trials Group; European Association of Urology Nurses; and universities across Australia. The statement recommends:

    After the diagnosis of prostate cancer and regularly through treatment and surveillance, men who have been diagnosed with prostate cancer should be screened for distress and their psychological and quality of life concerns should be explored.
    Men who have high levels of distress should be further evaluated for anxiety and/or depression and evidence of suicidality.
    Men who have high distress or need for support should be referred to evidence‐based intervention matched to their individual needs and preferences for support.

    Research is needed to develop effective methods to identify partners of men with prostate cancer with high distress or who are at risk of high distress as well as effective interventions for partners and for couples where the man has a diagnosis of prostate cancer.
    Investment in prostate cancer survivorship research is a national health priority.
    It does not seem a difficult or insurmountable health system change to screen for distress after a diagnosis of cancer and to refer to relevant support, yet implementation continues to lag (Lazenby, Tan, Pasacreta, Ercolano, & McCorkle, 2015). The administration time for a single‐item distress thermometer and problem checklist can be measured in brief minutes. But most importantly, this brief screen initiates the patient's self‐appraisal of distress and guides clinical staff not only on the level of distress, but also on the source or sources of concern for the man.
    An evidence‐based monograph has been produced to guide the health sector in taking action to implement screening for distress and referral for men with prostate cancer to psychosocial health care resources (Chambers, Galvγo, et al., 2019; available at https://www.pcfa.org.au/). Learning tools have been developed and are in trial. Recently, Lazenby and colleagues reported the successful dissemination and implementation of psychosocial distress screening at 72 cancer centres in North America (Lazenby et al., 2019). The involvement of key stakeholder groups was crucial to the success of this programme, and with this involvement came the commitment of resources. Awareness, education and skills training to support actual implementation needs to be context‐relevant and accessible. Our approach is consistent with this.

    For men with prostate cancer in our setting, the first key steps for implementation are in play: a published and context‐relevant evidence base developed with the support of key stakeholders by a dedicated community‐based consumer organisation, the Prostate Cancer Foundation of Australia, advocating independently for change. Position statements are only of value when adopted into routine practice, and therein lies the challenge: we must move beyond feeling to thinking and acting. Returning to CS Lewis (1961), the observation that ‘attention is an act of will’, and ‘intelligence in action is will par excellence’. This is our challenge as health professionals in oncology. We have the knowledge. Do we have the will?
    [Emphasis mine]


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