Challenges in the management of prostate cancer
* Widespread PSA screening has lead to over-detection and over-treatment that can cause undesirable side effects which can impact the quality of life. The answer is, not to stop detecting cancers but rather to do it more efficiently, cost effectively and treat only those men that need treatment. Men could postpone therapy if they have low-risk cancers. After diagnosis, active surveillance and careful monitoring can be used in men who are thought to have low-risk cancer. However, is no reliable way to determine which cancers will progress except by monitoring definitively. Even if a man is believed to have low-grade cancer no one can be sure. Newer techniques of detection and biopsy may reduce exposure and reduce overdiagnosis Men have to know the risks of active surveillance, and it may not be appropriate for younger men who are in good health with long life expectancy. For men who cannot handle the anxiety of not knowing if cancer will progress alternative treatments are available that can treat cancer focally with fewer side effects. Focal therapy or hemi gland therapy using techniques such as High-Intensity Focused Ultrasound (HIFU) is available as better methods of imaging and monitoring become widespread. It is just as important to personalize treatment strategies as it is to customize detection strategies. The era of radical prostatectomy and high dose radiation for low-grade cancers is being questioned. This ‘one size fits all’ treatments are no longer justified because they can be unnecessary and have unacceptable side effects.
If anxiety and psychologic burdens of living with cancer are unacceptable men could evaluate minimally invasive newer treatments such as HIFU that can treat the cancerous areas without destroying the entire prostate. This will result in less sexual dysfunction, incontinence, and other side effects.
*Experts have published techniques of ‘smart screening’ in the field. These strategies can be personalized for individuals based on age, life expectancy, health status, and personal preferences.
However, abandoning early detection of prostate cancer is not a wise choice because of several reasons. The incidence of prostate cancer is expected to increase in in the next several decades because of population demographics in the US. 97% of prostate cancers occur in men over age 50. Over 80% of prostate cancer deaths occur in men over age 65. The population of men in the USA aged 65 years and older has increased by 25% from 2003 through 2014. There were 44 million men over age 65 in 2010, and this is expected to go up to 88 million by 2050. worldbank.org/indicator/SP.POP.65UP.TO.ZS
. -US census data
Older men are infrequently screened for prostate cancer because they are thought to be frail and in poor health. However, prostate cancer can be deadly in older men. Men over age 75 account for more than half of all men who die from this cancer. A 75-year-old has a good chance of living to be 85 if his overall health status is functional. What is needed is not to ignore his cancer but to evaluate it and look at various options. Except for radical surgery, other options are available to treat older men.
Controversy in prostate cancer is the use of blind biopsies to detect cancer
the debate is in partial vs. whole gland treatment
Radiation versus surgery has mostly been resolved
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 the introduction of 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 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, who 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 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 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.