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The Prostate Cancer Quandary

October 05, 2011

EDITOR'S NOTE: This blog was originally published on June 29. Due to recent questions on this topic, it's been reposted. News reports say the United States Preventive Services Task Force will next week release new recommendations saying that healthy men should no longer receive a PSA blood test to screen for prostate cancer. Reports say the USPSTF will say the test does not save lives and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence. Otis W. Brawley, M.D., chief medical officer of the American Cancer Society, says the Society cannot comment on the evidence review or on the recommendations until they are made public.

By Otis W. Brawley, MD, FACP

 

 

Prostate cancer is a major public health problem.   The American Cancer Society estimates that 240,890 American men will be diagnosed with prostate cancer in 2011 and 33.720 will die of it.  It is the second leading cause of cancer death among men, only surpassed by lung cancer. 

 

Prostate cancer screening became common in the U.S. in the early 1990s and dramatically changed the demographic of cancer in the U.S. Prostate cancer quickly became the most commonly diagnosed non-skin cancer.  Today an American male has a lifetime risk of prostate cancer diagnosis of about 1 in 6 and a lifetime risk of dying of only 1 in 36. In Western European countries where screening is not common, the lifetime risk of prostate cancer diagnosis is much lower, about 1 in 10, and the lifetime risk of death is the same.

 

Screening began without the completion of the scientific research to show that it saves lives. For most advocates of screening and aggressive treatment, there was and is a desire to do something that might be beneficial to the population of men at risk. Unfortunately, the history of medicine is filled with examples of physicians "jumping the gun" and using possible interventions before they are fully evaluated.

 

The problem with prostate cancer screening is this cancer has a varied biologic behavior.  Many, perhaps even most, men with diagnosed localized prostate cancer have a disease that will never progress and cause harm.  Treatment for these men will only cause side effects.  They are cured, but do not need to be cured. 

 

On the other hand, some men with apparently localized disease have a cancer that will progress and ultimately kill. Treatment of these men may save them from a prostate cancer death. 

 

The quandary in prostate cancer medicine is best summarized by Dr. Willet Whitmore, former Chief of Urology at Memorial Sloan Kettering Cancer Center: "When cure is possible, is it necessary? When cure is necessary, is it possible?" 

 

Another very wise urologist, Dr. Paul Shellhammer, once used the words of Whitmore to further explain that we know there are two kinds of prostate cancer and we hope there is a third. 

 

  • 1. There is the kind that can be cured, but need not be cured.
  • 2. There is the kind that needs to be cured and cannot be cured.
  • 3. We all hope there is the kind that needs to be cured and can be cured.

 

 Recommendations Acknowledge Uncertainty

 

"Do screening programs save lives?" is a legitimate question. In the past 2 years there have been several publications of interim analyses of large prostate cancer screening studies causing several organizations to re-evaluate their prostate cancer screening recommendations.  It is of note that all major organizations that have a process for evaluating data and developing screening recommendations recognize that the utility of PSA screening is legitimately open to question.   All statements leave open the possibility of a benefit to screening but they note that the harms of screening are better proven than the benefits. 

 

  • The American Urologic Association in its 2009 "PSA Screening Best Practice" statement recommends that prostate cancer screening be done but says, "Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical. Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion. "
  • The European Association of Urology has made a statement that recommends for informed decision making within the physician-patient relationship and against mass screening in which informed decision making is difficult. They state, "Men should obtain information on the risks and potential benefits of screening and make an individual decision."
  • The National Comprehensive Cancer Network says, "There are advantages and disadvantages to having a PSA test, and there is no 'right' answer about PSA testing for everyone. Each man should make an informed decision about whether the PSA test is right for him."
  • The American Cancer Society screening statements have been largely consistent with the above statements since 1997. The 2010 ACS statement says, "men should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening."

 

The controversy concerning the usefulness of PSA screening is likely to continue for some time.  Even many physicians do not understand that screening and aggressive therapy might be net harmful for the population of men at risk. It is best that men and their physicians be:

 

  • Aware that there is a legitimate controversy about screening.
  • Familiar with the recommendations of these organizations.

 

A man choosing regular screening might benefit in that his life might be saved.  That man might also be harmed by suffering the effects of unnecessary diagnosis and treatment.  I say "unnecessary diagnosis" as there are now studies showing that men concerned about a diagnosed prostate cancer have a higher risk of depression and suicide. 

 

We all need to keep an open mind regarding screening and support the basic and clinical research which might ultimately allow us to predict the localized prostate cancers that are destined to progress versus those localized cancers that are destined to remain dormant.  If we find and validate such a test we can actually determine just how good our current treatments are.

 

 

Comments

8/23/2011 11:37:21 AM #

Leonard Evens

Your discussion is helpful, but it is important  to note that the recommendations are based on averages.  so they may or may not apply in a particular case, and the same is true of what a man's doctor can say to him.

Let me describe my case as an example.  At age 67, I had a biopsy, when my PSA exceed 4.0, based more on the PSA velocity than the actual value.  I was diagnosed with a  Gleason 7=3+4 prostate cancer, which I chose to have treated by surgery.   11 years later I have been recurrence free.  I have some minor stress incontinence, which is not very different than what I had before surgery.  I was impotent for 18 months and used pump during that time.  I recovered erections afterwards.  I use Viagra but sometimes I manage without it.  My wife and I enjoy an active sex life,  now into our late 70s.

The great majority of prostate cancers, which are treated by surgery or radiation, are Gleason 6.  Some large unknown percentage of these probably don't need to be treated.   But for a man like me in his late 60s with a 10 year expected lifetime, a Gleason 7 is another matter.  As best I can tell, even in the 7=3+4 case, the chances of developing metastatic prostate cancer in 10 or more years is higher, I think, than any rational man would accept.   The chances of a cure are also uncertain, but, on balance, I think I made the right decision.

Had I been Gleason 6, the issue would not have been as clear.  But how in the world could I have had the choice without PSA testing.  Had i waited until the cancer was large enough to be detected by digital rectal examination, or worse yet, until obstructive symptoms developed, the chances of developing metastatic disease would be very high, and the only option would be hormone therapy, which only delays the onset of serious symptoms and has serious side effects of its own.

I think that in my case, PSA testing followed by treatment probably extended my life.    Since it is not testing itself, but the decisions  made afterward about treatment that is relevant, that is where the emphasis should be put.  

Leonard Evens

8/23/2011 4:31:04 PM #

Mark Podob

I was diagnosed at age 59 with Stage 1 Prostate Cancer - my PSA increased from 2.4 to 5.6 in the course of a year. My urologist suggested a biopsy, which I had a done and cancer was detected. My Gleason was 3+3, and I was T1C. My initial choice was to pursue surgery as I had lost a brother-in-law to prostate cancer and did not want any shred of a disease. Fortunately I learned about proton beam therapy and had been accepted at the Hospital of the University of Pennsylvania. It is exactly a year since I completed the protocol. My PSA checked in at 1.9 last week and is expected to continue to decline.

While every many must make a decision about testing and treatment, I think that it absolutely nuts not to be tested. Sure, the biopsy is painful - especially if your urologist is stingy with the localized anesthetic,  Lidocaine as he was in my case, and certainly there may be false-positives test results, but one thing is clear -- a PSA test and a biopsy can save lives.

Certainly a 75 or 80 year old man who is diagnosed with prostate cancer may opt not to pursue any type of treatment, but for virile younger men, in their 50's and 60's not to choose a treatment is pure nonsense. And to pursue surgery with the risk of incontinence, impotence, infection and other life threatening side is simply not a rational decision. Thank goodness that Loma Linda, and the seven (soon to be eight or nine) proton beam centers had the foresight to invest in this amazing technology. And for donors like Roberts and Perelman who contributed millions of dollars to the Hospital of the University of Pennsylvania where I was fortunate enough to be treated.

I  think that it is criminal for urologists and government agencies, and yes, even the American Cancer Society, not to promote proton beam therapy. I found out about this treatment through friends and by word of mouth, and then through "Proton Bob" Marckini and his book. If ever there was a silver bullet treatment, this is it -- I had absolutely no side affects whatsoever, and unlike the previous responder, do not have stress urination, did not need a pump, and have no need for Viagra to achieve an erection and have satisfying sex. When I informed my urologist, who was a surgeon, of my decision to pursue proton beam therapy, he told me that this was an experimental procedure, and I would do well to reconsider. Poppycock.

Mark Podob

8/26/2011 10:43:07 AM #

Gary Edwards

While the PSA test doesn't tell us everything we would want to know, I view it a vital test.  I had PSA tests going back to 1998 and a constant rise to 4.2 last year at 54 years of age.  I should have been more sensitive to the 2.5 I had when I was 50.  I think the key is to understand that there are other tests to help determine the probability of whether it's cancer or not.  I had a free PSA test which at 11% pointed in the direction of cancer, and the fact that one male relative had it convinced me that the biopsy was the right thing to do.  I was not surprised when the biopsy found cancer.  The Gleason was a 3+4 7, and I completed proton beam radiation therapy about two months ago.  

I echo Mark's comments about proton beam therapy.  My urologist told me it was experimental (it's not) and a conventional radiation oncologist I consulted said that there were no benefits over conventional radiation therapy (that's not what the data shows).  I found it by searching the internet and I read Bob Marckini's book.  Two months out, no side effects, but I never would have known about this therapy if I had relied solely on my doctors.

Gary Edwards

8/29/2011 10:53:54 AM #

Leonard Evens

In response to the comments above, let me add that the chances of impotence following treatment increase rapidly as a man enters his 60s.   Had I been ten years younger when I had my surgery, I think I would have stood a good chance of avoiding impotence entirely.  Also, as I noted, my (minor) stress incontinence is not much different from what I experienced before my surgery.   Also, the purpose of all treatment for prostate cancer is to essentially destroy or remove the prostate.  Anything less than that runs the risk of recurrence.   It is possible that by more precise focusing, proton beam therapy may avoid the bowel problems that are common with radiation therapy, but it can't possibly be aimed just at the cancer.  Any kind of radiation will produce side effects further down the line, while surgery produces side effects immediately, from which there may be significant recovery.

If Mark is doing as well as I when he is 78, he may want to boast, but I think it is premature to do so before that.

Both radiation and surgery are reasonable choices to treat prostate cancer.   Which one a man chooses, or whether he chooses any treatment at al, will depend on  his age, the nature of his cancer, and other personal factors.

Leonard Evens

9/16/2011 7:25:18 PM #

Robert L. Macchia

I was diagnosed with aggressive prostate cancer in Jan. 2011 after a biopsy and digital exam.  Only 8 months prior,  nothing was found after a digital exam.  

I entered the hospital and had the entire prostate removed by my urologist.  I went home and about 10 days later and had difficulty urinating, passing air through my penis and grit in my urine.  Unknown to me I had developed an upper and lower colon infection.  My urologist told me to go to the ER due to these complications.  I was admitted and ended up in the hospital for over a month.  I also had enemas of antibiotics, and tubes inserted into my kidneys for drainage and a temporary ileostomy, that will be reversed the beginning of 2012.  And will have radiation ONLY as a precautionary measure due to the aggressive cancer that was found.  I am receiving lupron injections to arrest any spread of cancer.  
I am presently cancer free, thanks to God.

My message to all men over 40, or before if you have urination problems, is to have an annual prostate digital exam and follow your doctors advice.  Robert L. Macchia, Suffolk County, NY

Robert L. Macchia

10/6/2011 11:56:48 AM #

leonard Evens

Robert Macchia's experience raises a couple of important issues.

First, as he emphasizes, a digital rectal exam, by itself, may miss an aggressive cancer, which may show up as the result of a PSA test.  The problem with PSA tests seen by many experts is that often as the result of such a test a man may seek treatment which is not really necessary.  But I think that rather than not having regular PSA tesst, a man who is diagnosed as having a cancer as the result of one,  must be very careful about deciding whether or not to proceed with further treatment.   For example, and older man who is diagnosed with a low grade cancer may reasonably decide to follow it carefully rather than proceed with more aggressive treatment.    (Men past a certain age should probably not have PSA tests at al)l.  On the other hand a younger man with an  aggressive cancer will probably want to have it treated.

Second, bowel complications after surgery a rare.  They are more common after radiation because it is hard to restrict the radiation to the  prostate alone.

leonard Evens

10/11/2011 10:11:08 AM #

braillon

Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
[LINK REMOVED DUE TO BLOG COMMENT POLICY]
The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime
The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime. There is also adequate evidence that the screening process produces at least small harms, including pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.
The USPSTF concludes that for men younger than age 75 years, the benefits of screening for prostate cancer are uncertain and the balance of benefits and harms cannot be determined.
For men 75 years or older, there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits.
Given the uncertainties and controversy surrounding prostate cancer screening in men younger than age 75 years, a clinician should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the known harms of prostate cancer screening and treatment. Men should be informed of the gaps in the evidence and should be assisted in considering their personal preferences before deciding whether to be tested.

braillon

10/16/2011 2:48:15 PM #

Dave Hansen

Reading these comments encourages me that the treatment options I'm pursuing are right for me. I've had 4 years of PSA and DRE testing. Four years ago my PSA was elevated at 3.5. This March it was 7.5 and in August it was 11.1. Because of the steady rise and accelerated numbers, I had a biopsy. With 4 injections of novocane(?), the 18 biopsy needles were easy, though I was very apprehensive about this test. While no cancer was detected at the base or mid regions, the apex had Gleason readings of 6=3+3 and 7=3+4. This puts me in the Early-stage, mid-risk category. I'm 64 and my urologist recommended proton radiation therapy based on these factors. Active Surveillance would mean PSA tests every 4 months and another biopsy in a year. My urologist said there is a risk that within 10 years cancer would spread outside of my prostate. Prostate cancer is a painful death. I don't like pain and probably won't like death. I'm too great a risk for surgury and my prostate is enlarged so brachytherapy is not an option either. I'm 20 minutes from a Proton Therapy center so it seems the path for me is laid out.

Dave Hansen

10/17/2011 12:17:58 PM #

Leonard Evens

Dave,

I think you definitely made the right decision.   With some Gleason 7=3+4 cancer,  the risk of developing metastatic cancer in the next ten years is too high to ignore.  Not only do you risk the effects of the cancer, but the only treatment option you would have in tha  case would be hormone therapy,  the side effects of which are not pleasant., and such therapy will ultimately fail, possibly in only a few years.

Those who argue that PSA testing is not generally helpful seem willing to sacrifice the minority of us with Gleason 7 cancers in order to avoid overtreatment for the majority of men with lower risk prostate cancers.     Perhaps someday researchers will find a test which doesn't lead to such  overtreatment, but that hasn't happened yet.  

Leonard Evens

10/22/2011 1:22:04 PM #

kwasi ansong

Very helpfull comments. PSA level of 4.66 and Gleason 6, my Urologist recommending surgery to cure the cancer found in my prostrate. Not sure if I should do radiation or surgery. After reading above comments, Proton Beam therapy may be my choice.  

kwasi ansong

10/24/2011 10:17:42 AM #

Leonard Evens

To Kwasi Ansung:

I strongly advise you NOT to choose your therapy based on what you read here.  First, discuss with your urologist the choices which make the most sense for you.  If, after that,  you don't feel you have confidence in your urologist, seek a second or even a third option from another urologist.

Proton beam therapy is one form of radiation.  It is claimed that because the beam is better focused it doesn't affect the surrounding structures as much as other forms of radiation which use Xrays.   But I don't think, as of 2006,  that had been established by a rigorous study comparing different radiation therapies.  Anecdotal information in a blog doesn't count.

In general, both surgery and radiation can lead to impotence.  In the case of surgery, the impotence is immediate and then may resolve after a period of time.  Radiation, on the other hand, may produce impotence after a couple of years.

Good surgeons in younger men can avoid long term impotence in the great majority of cases.  In older men, surgeons have a harder time avoiding impotence and radiation may be the better choice.

If your cancer is only Gleason 6, depending on your age, "watchful waiting" may be a viable option.   A lot of Gleason 6 cases probably won't ever bother the man during his lifetime, but unfortunately there is no good way to easily distinguish, between aggressive prostate cancers and non-aggressive ones.   Again,  you shouldn't make such a choice except under the guidance of a good urologist.

I strongly recommend  "The Prostate Book" by Peter Sardino as a reliable guide.

Leonard Evens

10/24/2011 11:25:18 AM #

Mark Podob

To Kwai Ansung -

I would hardly call my comments relative to proton beam therapy as "anecdotal". Your suggestion to explore proton beam therapy as an alternative to removal of your prostate is a smart decision, as is looking at other forms of treatment. I suggest that you also get a copy of "You Can Beat Prostate Cancer" by Bob Marckini, the definitive book on proton beam therapy. Mr Evens comments regarding proton beam therapy are just incorrect.

Here is a summary of the history of proton beam therapy:

The first suggestion that energetic protons could be an effective treatment method was made by Robert R. Wilson in a paper published in 1946 while he was involved in the design of the Harvard Cyclotron Laboratory (HCL). The first treatments were performed with particle accelerators built for physics research, notably Berkeley Radiation Laboratory in 1954 and at Uppsala in Sweden in 1957. In 1961, a collaboration began between HCL and the Massachusetts General Hospital (MGH) to pursue proton therapy. Over the next 41 years, this program refined and expanded these techniques while treating 9,116 patients before the Cyclotron was shut down in 2002. The world's first hospital-based proton therapy center was built in 1990 at the Loma Linda University Medical Center (LLUMC) in Loma Linda, California. Later, The Northeast Proton Therapy Center at Massachusetts General Hospital was brought online, and the HCL treatment program was transferred to it during 2001 and 2002. By 2010 these facilities were joined by an additional seven regional hospital-based proton therapy centers in the United States alone, and many more worldwide.

I am not certain about Mr. Evens is a physician (nor am I), so his comment that you should seek a good urologist opinion on treatment is correct - but clearly a second opinion from a radiation oncologist should be part of your decision making process.

Mark Podob

1/14/2012 12:04:02 PM #

Robert A. Smith

I am a 52 year old who was just diagnosed with PCA having a Gleason of 3+4.  The biopsy was positive in one of 8 cores and my doctor recommended open surgery because PSA socres may rise over time with radiation treatments. My father was diagnosed with PCA when he was 69 and it had spread to his back, he passed from having metastatic PCA at age 74. I am strongly leaning towards surgery to get it out of me and because the surgeon can also see if it has spread.  Are long term results for Proton treatments different that other focused radiation treatments (I will get the book(s))?    

Robert A. Smith

2/25/2012 9:35:51 PM #

Marcel Daigneault

Health Discovery Corporation Agrees with the U.S. Preventive Services Task Force’s Position Against PSA-based Screening for Prostate Cancer and Believes its Four-Gene Assay for Prostate Cancer is the Best Alternative to PSA
[URL removed per blog comment policy]

Marcel Daigneault

3/19/2012 11:43:37 AM #

Ray Spiess

Of all the factors forcing changes in P.S.A., only prostate cancer will elevate P.S.A. in an exponential growth.  Why there has been no study to apply exponential P.S.A. growth as a prostate cancer marker . . . I don't know.

Ray Spiess

5/25/2012 12:20:35 PM #

Terrie Hahn

My husband is 58 and had a quickly rising PSA starting last fall.  In January, his Gleason after biopsy was 9.  He had his prostate removed along with a lymph node.  The cancer was miniscule in the lymph node and was also in the seminal vesicle.  His local oncologist sent him to a Doc at Hermann in Houston.  He is watching the PSA.  It has gone from .4 six weeks after surgery to .5 nine weeks after surgery.  He is waiting to see what the PSA does in the next few weeks.  He suggests going on a study he has involving combination of chemo and hormone therapy.  In the meantime, we went to MD Anderson in Houston for a second opinion.  The doc there suggests salvage radiation.  The PSA in their lab has stayed at .4.  They have done CT scans, bone scans and MRI's  and none have shown any VISIBLE cancer.  

So what do we do now?  Radiation, the study with chemo/hormone therapy that hasn't be shown to work, or watch the PSA and see what happens over time.  I have put him on a strict no meat or dairy diet.  But he was 80 % vegetarian when this all came about.  This whole experience has been utter confusion.

Terrie Hahn

12/12/2012 10:48:13 PM #

nick grillo

just finished 2 months of radiation treatments for prostrate cancer also have lupron hormone shots every 3 months had cancer in my prostrate only bones and lymphnodes were clear getting hot flashes have not tried sex in 2 months the problem that bothers me the most is im peeing at night every 90 minutes like clock work seein my dr. next week...is my bladder going to get stronger like before the treatments   someone have the answer???

nick grillo

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