Challenges in the management of prostate cancer
*Widespread PSA screening has led to over-detection and over-treatment of prostate cancer, which can result in undesirable side effects and negatively impact quality of life. The solution is not to stop detecting cancers, but to do so more effectively and cost-efficiently, treating only those who require treatment. Men with low-risk cancers could consider postponing therapy.
After a diagnosis, active surveillance and careful monitoring can be utilized for men identified as having low-risk cancer. However, there is currently no reliable method to predict which cancers will progress, other than ongoing monitoring. Even if a man is diagnosed with low-grade cancer, certainty about its behavior cannot be guaranteed. Newer detection and biopsy techniques may help reduce the risk of overdiagnosis and unnecessary treatment.
Men need to understand the risks associated with active surveillance. This approach may not be suitable for younger men with a long life expectancy and good health. For those who struggle with the anxiety of uncertain cancer progression, alternative treatments can target cancer locally with fewer side effects. Treatments like focal therapy or hemi-gland therapy, which use techniques such as High-Intensity Focused Ultrasound (HIFU), are becoming more widely available as better imaging and monitoring methods emerge.
Personalizing treatment strategies is crucial, including tailoring detection methods. The traditional approaches of radical prostatectomy and high-dose radiation for low-grade cancers are increasingly being questioned. Such “one-size-fits-all” treatments are often unjustified as they can be unnecessary and carry unacceptable side effects.
Suppose the anxiety and psychological burdens of living with cancer become overwhelming. In that case, men might consider minimally invasive newer treatments like HIFU, which can target cancerous areas without removing the entire prostate. More advanced newer treatments can target cancerous areas without removing the entire prostate. However, it is essential to note that these treatments may still result in minor sexual dysfunction, incontinence, and other side effects.

Experts have published techniques for “smart screening” in prostate cancer detection. These strategies can be tailored to individuals based on factors such as age, life expectancy, health status, and personal preferences.

However, abandoning early detection of prostate cancer is not a wise choice for several reasons. The incidence of prostate cancer is expected to increase over the next several decades due to changing population demographics in the U.S. Currently, 97% of prostate cancers are diagnosed in men over the age of 50, and over 80% of prostate cancer deaths occur in men over 65. The population of men aged 65 and older in the U.S. grew by 25% from 2003 to 2014. In 2010, there were 44 million men in this age group, and that number is projected to reach 88 million by 2050 (source: worldbank.org/indicator/SP.POP.65UP.TO.ZS).

Older men are often presumed to be frail and in poor health, which leads to them being overlooked for prostate cancer screenings. However, prostate cancer can be fatal in older men; more than half of all men who die from this disease are over 75. If a 75-year-old man is in good health, he has a reasonable probability of living to 85. Rather than ignoring potential cancer, it is essential to assess his condition and consider various treatment options. Aside from radical surgery, there are several other treatments available for older men.

There are several controversies in prostate cancer diagnosis and treatment. The first controversy in prostate cancer regards early detection. In the US, most men over the age of 50 get a prostate-specific antigen test. Over 95% of male Urologists and 78% of primary care providers who are 50 years of age or older have had a PSA test themselves. US Death rates from prostate cancer have fallen 50% over the years since 1990, five years after PSA testing.

Advantages of PSA: Actual and projected death rates Prostate Cancer, 1975 to 2020, CDC Data Death rates peaked in 1990 when PSA use peaked, and since then, 50% decrease in death rates due to the widespread use of PSA.

JE Shoag, S Mittal, New York-Presbyterian, Jim HU Weill Cornell University

“90% of controls in the PLCO trial had at least 1 PSA test before or during the trial.”
“Men in the control group had more testing than intervention arm.”
“The contamination in the PLCO trial makes it unreliable to determine the role of PSA in prostate cancer death rate.”

In a European study of screening for prostate cancer, the authors reported that PSA screening with a rectal exam resulted in a 21% reduction in the death rate of prostate cancer in a follow up of 13 years.
PSA Reduces Death Rate

One randomized trial of screening PSA vs. no PSA, the ERSPC trial. 182,388 men – 900 cancer deaths
13 years of follow up
PSA testing every 2-4 years vs. standard of care with no PSA
Men aged 55-69 years at the start of the trial
PSA screening arm shows a 21% reduction in prostate cancer death at 13 years
27 men need to be diagnosed to prevent one death

Despite these studies, there is still some controversy in the minds of some physicians on the use of PSA in Prostate Cancer.

The other question for physicians and patients is if the PSA is elevated and should get a biopsy. The only way to diagnose prostate cancer is by a biopsy. There are some side effects of biopsy, mostly related to infection. The side effects of infection have diminished significantly with current protocols of antibiotic use. However, repeated biopsies in patients who choose active surveillance can cause morbidity. For further discussion on the types of biopsy and the advantages of each, please go to our other website prostatecancerfacts.net and click on the section titled Biopsy or No Biopsy!

Once cancer is diagnosed, there is another controversy as to who should get treatment. Currently, it is believed that patients who have small cancers under 1cm in size and have a Gleason score 6 (Gleason score is a grading of prostate cancer, and 6 is considered low grade) should be on active surveillance. The term active surveillance, according to American Urology Association guidelines, implies that patients should be followed carefully with serial PSA and undergo prostate biopsies every 1 to 2 years. Many patients are unwilling to undergo biopsies this frequently, and also, there is anxiety associated with this follow-up.