Prostate Cancer Screening Saves Lives

Over the last 30 years, I have been witness to a remarkable change in how we diagnose and treat prostate cancer. Prior to the mid-1980s, prostate cancer was detected most often when symptoms of advanced prostate cancer were present, such as bone pain from metastatic disease. Very few patients were diagnosed at a curable stage.

The PSA (prostate-specific antigen) blood test came into wide use around 1986 when the FDA approved it for monitoring known prostate cancer. In the early 1990s, physicians started ordering it to detect early, asymptomatic prostate cancer. A spike in prostate cancer diagnosis happened. This wave of patients was a boon to treating physicians, primarily urologists who operate on prostate cancer, but also for radiation oncologists who treat cancer with various types of radiation. More early diagnoses also led to more clinical trials about how best to treat prostate cancer.

We learned a lot. Techniques for removing the prostate got better with the advent of robotic-assisted prostatectomy, as did precision and dose of radiation delivery with intensity modulated radiation treatment. The 15-year relative survival rate for prostate cancer is now an astounding 95%.

But we also learned that not every man with prostate cancer needs treatment.

How can we say this? How can we diagnose someone with cancer and then say, “Oh, by the way, you don't need to do anything about it”? Add to this confusion the 2012 US Preventive Services Task Force recommendation to do away with screening altogether because of the risk of over-diagnosis and harm. In my opinion, that is a dangerous step backward for many of us guys who will get prostate cancer.

Granted, we are too aggressive about treating some prostate cancers. It is easy to vilify doctors who are incentivized to treat rather than watch and wait. But I think a big part of the problem in the US is that patients don't want to be told they have cancer and nothing needs to be done about it, especially when all this wonderful technology exists and insurance will pay for it.

What’s the solution?

We have very good tools now for determining aggressiveness of an individual patient's prostate cancer. That, along with evaluation of a patient's age and overall health status, helps us predict quite well whether or not a particular patient's prostate cancer will ever be a problem for them without treatment. Over treatment can be just as much of an error as under treatment or the wrong treatment. Know all your options for treatment if you need it; no single treatment is right for everyone. Get a second opinion if you haven’t gotten a good explanation about your need for treatment and what your full options are. And, yes, don’t even get screened for prostate cancer if your age and health status are such that you wouldn’t benefit from treatment anyway.

In the near future, there are certain pathologies that we call cancer now that we will no longer label as malignant, as they simply don't act like cancer. (It is a lot easier to say we don't need to treat a condition if we don't call it cancer.) In addition, genetic testing may add to our ability to individualize decision-making based on aggressiveness and risk of spread and progression of disease.

The American Cancer Society continues to support screening for prostate cancer, because they know that screening saves lives. If you are 50 or older – 45 for African American men – and are likely to live for ten years or more, get a PSA blood test. Do it regularly. Go to www.cancer.org for more information. Man up; take charge of your health.

Prostate Cancer: How Should We Treat It?

Prostate cancer screening and treatment may be the most divisive issue in oncology today. Oh, we argue about breast cancer, and whether or not women in their 40s should get a mammogram (they should), and how often they should get one (every year). But prostate cancer is even more controversial. That's because prostate cancer is not a single disease with just one way to treat it.

We divide prostate cancer patients into three risk categories: low, intermediate, and high risk. Risk of what? Risk of spreading and killing you, basically.

We place patients in these risk categories based primarily on how high the prostate specific antigen (PSA) blood test is, and how aggressive the prostate cancer biopsy specimen looks under the microscope (the so-called Gleason score). Low risk patients (PSA less than 10, Gleason score 6 or less) have a 90% survival rate at 10 years, which is fantastic. High risk patients on the other hand (mainly those with PSAs greater than 20 or Gleason 8-10) have aggressive cancers and only a 50% survival rate. Finding a prostate cancer when the PSA is lower and the cancer is less aggressive is better. But...

The problem is, we are now finding some cancers so early that they don't even act like a cancer; they will never spread or cause a problem. The conundrum is determining which cancers those are, because we still live with fear of the word "cancer" and assume that something must be done whenever it is diagnosed. Even more problematic, we too often assume that we must have surgery and "cut it out", when that may not be what is best, much less what is needed at all.

Yes, we over-diagnose and over-treat prostate cancer. Now, I am not a hardliner who says we shouldn't be screening for prostate cancer. Far from it. The American Cancer Society recommends that "men make an informed decision with their doctor about whether to be tested for prostate cancer." How old are you? What health problems do you have?

"Starting at age 50, men should talk to a doctor about the pros and cons of testing so they can decide if testing is the right choice for them. If they are African American or have a father or brother who had prostate cancer before age 65, men should have this talk with a doctor starting at age 45."

Remember, however, that even if you learn you have prostate cancer, you do not necessarily need treatment! Certainly, don't jump in and have major surgery without checking out all your options, including that of observation. On of the oldest statements in medicine is primum non nocere - first, do no harm. That holds true today as much as it did when that ethical concept was included in Hippocratic Oath in the 5th century BC.

If treatment is recommended, we are fortunate at CHI Memorial to offer a very precise form of radiation treatment called Intensity Modulated Radiation Treatment (IMRT) for prostate cancer. This pinpoint, outpatient treatment is every bit as effective as surgery with few side effects. It also does not have the risk of long-term incontinence that comes with surgery.If you or a loved one you know gets diagnosed with prostate cancer, or even just has an elevated PSA, please do not rush to surgery. Certainly, we have skilled surgeons in East Texas, but take your time and get a second opinion to determine 1) whether treatment is the best option, and 2) whether surgery or radiation is a better option for you.