“What should I do about my prostate?” you ask.
If you are 80 years old and need a challenge in life, consider a prostate biopsy. There’s an 80 percent chance you have cancer. If you are 50 years old, the risk of a malignant diagnosis is closer to 50 percent.
I shun the prostate-specific antigen test for myself, based partly on information, partly on confusion.
Let’s assume cancer is found and is said to be localized. You are urged to consider treatment. The options include radiation, surgery, hormonal treatment, observation or doing nothing.
Next month I’ll try to help you understand the advantages and disadvantages of different therapies.
My concern is whether any of the interventions work and why important studies show little or no effect of PSA screening on survival.
So let’s start with the assumption that some of the attacks on prostate screening could expose bad data or a conspiracy by government and/or industry to deny care. Look at the data and decide for yourself.
In May 2012 the U.S. Preventive Services Task Force released a statement recommending that PSA testing be stopped for all men, at all ages.
Wow. Had we been that far wrong?
The American Urological Association and most practitioners rejected the opinion. It was argued the panel didn’t include cancer specialists.
That is true, but the panel did include experts who may have been more appropriate. The team of volunteers had experience in evaluating data and appeared neutral to the interests of the cancer-care industry. Members were appointed by an agency within the Health and Human Services Department.
They are relatively insulated from political pressure. If they were not, they were unlikely to make decisions that politicians railed against, especially the 2009 decision that suggested we overused mammography.
In September 2012 the journal Science interviewed the committee chairwoman, Dr. Virginia Moyer. Moyer is a pediatrician, with a journalist father, a mother in the sciences, and expertise in evidence-based medicine. She takes a lot of heat for her positions.
The decisions against screening were supported by large studies — one in Europe and another in the U.S. Neither showed any improvement in overall survival.
The European study indicated a possible increase in survival in younger men who were screened and treated, but the American study didn’t show the same results.
A February 2012 article in Scientific American published the conclusions of a Harvard expert on prostate cancer, Dr. Marc B. Garnick. He stated that more than a million men have been treated unnecessarily for prostate cancer, as a result of screening.
“At least 5,000 of them died soon after treatment, and another 300,000 suffered impotence or incontinence or both,” Garnick wrote.
A Veterans Affairs study followed 364 patients for 10 years after either prostatectomy or observation. The survival difference was less than 3 percent. Surgery resulted in adverse events in more than 20 percent of patients within a month of the operation.
The argument hasn’t ended. The follow-up on a Scandinavian study was published March 6. It supports claims that younger men realize survival advantage if they had prostatectomy rather than observation.
There may be a role for younger patients, but there are a lot of questions to be answered. If the authors are right, it takes eight radical prostatectomies, with the attendant complications, to save one life. That’s the most optimistic report I’ve seen to date.
How could it be we are finding earlier cancers with PSA screening and treating them with curative therapies, monitored by falling PSA levels, and the main outcome has been complications?
As a physician who cared deeply about my patients, I never expected to see these results.
The explanation probably lies in two or three facts. PSA measures more than just cancer. Levels tend to rise with age and enlargement of the prostate. Inflammation, sexual activity and other factors also influence the PSA.
Doctors looked for levels that would predict cancer, and, guess what? Most of the biopsies were positive. Of course they would have been positive, even without a PSA test.
Most seniors have something in their prostates that would be called cancer, if biopsied. It is possible there are two large categories of prostate cancer, the indolent ones that progress so slowly but will never cause a threat in a patient’s lifetime and ones that have already seeded (etastasized) when the diagnosis is made.
Understand that spread of a million cancer cells isn’t likely to be found with our best techniques.
Inside this conundrum lies the fact we don’t have a single definition for cancer. We rely on what we see under the microscope. We assumed we could differentiate premalignancy that may need another event before it becomes invasive and obligate malignancy that is certain to become invasive.
DNA and other studies may help in the future. We need to get better at predicting outcomes and identifying the extent of disease.
The term, “misfearing” has been introduced to help understand the instinctive nature of fear. It plays a major role in the psychological effect of cancer and the enormous effect on the economics of the cancer related industries.
Please believe one thing. Many things motivate most doctors and other caregivers. On the whole, they are sincerely concerned about your welfare.
There is another thing that doesn’t require belief: Economics drive some decisions to buy, promote and pay for expensive technology.
Before you take your prostate on a trip to Cancer Centers of Anyplace, or a proton program, think hard. Ask questions. Read next month’s article.
Dr. Larry Mulkerin is a retired clinical professor and oncologist who lives in Walla Walla. A former U.S. Army Green Berets medical officer with experience in the Middle East, he also is the author of “The Ayatollah’s Suitcase,” a novel available at amazon.com and other online book retailers. He can be reached at firstname.lastname@example.org.