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Mason What clinicians should want from scientists

patients do so? Are there other agents which might be for patients; biopsies from metastatic sites may need
further combined? special procedures such as computed tomography-
guided biopsies; they may be unpleasant - biopsy
HOW CAN OUR SCIENTISTS HELP US TO in bone is notoriously painful and may even require
BETTER TREAT OUR PATIENTS? hospitalisation or a general anaesthetic, especially,
if multiple sites are to be biopsied at the same time.
As well as the ethical implications, the resource
If we are to transform the treatment landscape for implications for the NHS are far from trivial.
prostate cancer, clinicians and scientists must work
together ever more closely. Prostate cancer defeats us 3. Prostate cancer therapy, as with other types of
when we do not accurately stratify patients according to cancer, must evolve from an era of empiricism, to
their risk of dying of disease, when we fail to overcome the era of precision medicine [24] . The utopian vision,
the effects of tumor heterogeneity, and when our whereby a clinical sample somehow gets to the
attempts at therapy spur further disease evolution and lab, and a subsequent analysis leads to a report
the emergence of new resistance mechanisms. At the that precisely determines the required treatment,
same time, we over-treat men who in reality do not will be difficult at best and maybe impossible to
need it, and some of those men needlessly suffer long fully realise. It may not be helped if the laboratory
term side effects as a result. We have all recognised analysis is based only on a random sample from a
the need for the development of better biomarkers primary tumor, maybe taken years before the onset
that will characterise disease states. I suggest that of metastatic disease, which is the objective of the
study, though when such samples yield cells with
as clinicians we have a duty to help our scientific the characteristics of stem cells, the insights can be
colleagues, especially focusing our efforts on several striking [25] . Nonetheless, we may need to grapple
areas: with the practical, ethical, and clinical challenges
posed by metastatic biopics - and maybe not just
1. The various and peculiar clinical phenomena which once, but repeated during the course of a patient’s
we observe in our patients, through clinical trials, illness, in order to get a profile of their tumor that
and clinical observations. Another critical observation reflects the current status at a time when therapeutic
has been the emergence of new patterns of decisions are being made. If we can, in the future,
disease, maybe following the selection pressures on safely and reliably inhibit multiple signalling pathways
tumor cells resulting from more diverse and novel in tumor cells, then a more aggressive clinical
therapies. approach to tumor sampling might be justified.

2. The provision of tissue and blood samples in a DECLARATIONS
meaningful way. Samples from patients are usually
characterised in the crude terms that we use in Acknowledgments
the clinic; but, for localised disease, what do the M. Mason is grateful for helpful discussions and
terms “low risk”, “intermediate risk” and “high technical assistance provided by Norman J. Maitland
risk” actually mean? The data from the ProtecT and Klaus Pors.
trial, though from very small numbers of dying
patients, argue that these terms are no guarantee Authors’ contributions
that scientists will really be studying cells that are M. Mason conceived the idea and wrote the
indolent, or aggressive, if they use samples based manuscript.
on these labels. The best we can say is that tumors
that are “high risk” are more likely to harbour cells Financial support and sponsorship
with metastatic potential than say tumors that None.
are “low risk”. We know that prostate cancers are
often multifocal, and heterogeneous; how do we Conflicts of interest
overcome this? Perhaps circulating tumor products, There are no conflicts of interest.
including but not restricted to circulating tumor DNA,
will in time give some sort of precis of the profile of Patient consent
a tumor population. What about tumor evolution? Not applicable.
This would argue for repeated sampling in order to
give a longitudinal profile of tumor behaviour. This Ethics approval
does, however, carry some significant implications Not applicable.

Journal of Cancer Metastasis and Treatment ¦ Volume 3 ¦ November 17, 2017 275