September is Prostate Cancer Awareness Month. Prostate cancer is the most common cancer among men in the United States, after skin cancer. It is also the second leading cause of death from cancer in men. Data from the National Cancer Institute show that prostate cancer occurs more often in African-American men than in white men and that African-American men with the disease are more likely to die from it than their white counterparts.
Image by Direct Relief, via Flickr
According to the American Cancer Society, one in seven men will be diagnosed with prostate cancer in his lifetime. Some 233,000 new cases are diagnosed annually; Nearly 3 million U.S. men currently live with prostate cancer And ACS estimates that 27,540 will die from the disease in 2015. However, most men with prostate cancer — about two-thirds — are older than 65, and do not die from the disease but from other causes.
Finding and treating prostate cancer before symptoms occur may not improve health or help men live longer; nor does every diagnosis warrant intervention. In 2012, the U.S. Preventive Services Task Force recommended against routine prostate-specific antigen (PSA)-based screening for prostate cancer, concluding that the expected risks of PSA screening are greater than the potential benefit. These risks include false positives that can lead to unnecessary treatment, with serious side effects for what is typically a very slow-growing disease.
The task force found that treatment of the cancers found by the PSA test can have important, often lasting harms, such as erectile dysfunction (impotence) from surgery, radiation therapy or hormone therapy. Other potential harms are urinary incontinence from radiation therapy or surgery; problems with bowel control from radiation therapy; and a small risk of death and serious complications from surgery. Yet according to this New York Times story, older men still get PSA tests in spite of the USPSTF recommendations.
The American Cancer Society takes no position on treatment for low-risk prostate cancer in older males. They suggest that an informed decision be made by a patient in consultation with his provider. “The concerns are justified, but there are many misunderstandings about how often side effects occur, how severe they really are and what can be done to manage them and counteract their occurrence,” the Prostate Cancer Foundation website cautions. “Many of the side effects that men fear most following local treatment are often less frequent and severe than they might think.”
To add to the confusion, this article from Reviews in Urology points out that treating frail men over age 70 could deprive them of years of life. Aggressive treatment is not necessarily effective or appropriate, depending on a patient’s age, comorbidities, and type of cancer, this Medscape story points out.
For journalists covering prostate cancer, this list of prostate cancer organizations can help find expert sources and those who have been diagnosed. It could be interesting to compare those who opted for a particular treatment or combination therapy and those who did not. Check out this disease guide from The New York Times, which provides an excellent in-depth look at prostate cancer.
Other ideas:
- Speak with an urologist at a local teaching hospital for insight into prostate cancer’s impact on your community. How does your city compare with national statistics?
- Some local facilities tout minimally invasive approaches like cyberknife, radioactive seed implants, high-intensity focused ultrasound, intensive lifestyle changes, hormone therapies or immunotherapy. How effective are they? What are the side effects? What is the cost compared with traditional approaches?
- There are also walks, runs and other local events that can provide opportunities to speak with men who were diagnosed, or their families.
UPDATE: Since posting, the American Cancer Society has clarified that their guidelines cover early detection, not treatment, and that informed decision making is part of early detection. They have no recommendation on treatment. The blog has been updated to reflect this.
Overtreatment and sexual dysfunction
I used to write about prostate cancer for some of the medical publications years ago, and I’ve tried to keep current. As a rule of thumb, roughly half the patients who were treated with either surgery or radiotherapy were left impotent.
A friend of mine had prostate cancer, had surgery, and was left totally impotent. He even lost the pleasant feeling he would have sitting next to an attractive woman. Then, a year later, his PSA started climbing again. He asked his urologist, “Does this mean I had this surgery for nothing?” The urologist didn’t answer.
An almost-unreadable table on the Prostate Cancer Foundation website http://www.pcf.org/site/c.leJRIROrEpH/b.5822789/k.9652/Side_Effects.htm says that the rate of sexual dysfunction is a little more than half with surgery, a little less than half with radiation, and a lot less than half if the radiation is brachytherapy. I wonder about that, because when I was following it, brachytherapy wasn’t that much better.
It looks like the nerve-sparing radical prostatectomy that some of the centers were touting in consumer ads years ago turned out to be no better than the standard procedure.
I can’t find anything really current, but the New York Times had a summary of a 2011 JAMA article:
http://well.blogs.nytimes.com/2011/09/20/predicting-sexual-recovery-after-prostate-cancer/
Predicting Sex Life After Prostate Cancer
By Tara Parker-Pope
September 20, 2011
“Over all, just 35 percent of men in the surgery group, 37 percent of men in the radiation group and 43 percent of men in the brachytherapy group were able to have sexual intercourse two years after treatment.”
That’s a summary of eTable 2. Actually, you want to know what percentage of the men who were able to have sexual intercourse before surgery were able to have sexual intercourse after surgery, which is 42%, 69% and 65%. If radiation really is that effective in preserving sexual function, that’s a story. The problem is that they’re not randomized, controlled trials, so you don’t know. The main factors associated with sexual function, BTW, were age and number of disabilities (lower is better). So if younger people are more likely to get brachytherapy, that would bias the results.
http://jama.jamanetwork.com/article.aspx?articleid=1104401
September 21, 2011
Prediction of Erectile Function Following Treatment for Prostate Cancer,
Alemozaffar M, Regan MM, Cooperberg MR, et al.
JAMA. 2011;306(11):1205-1214. doi:10.1001/jama.2011.1333.
http://jama.jamanetwork.com/data/Journals/JAMA/22466/JWE15120_09_21_2011.pdf
eTable 2. “Summary of Erection Quality Prior to and at 2 Years After Treatment According to Planned Primary Prostate Cancer Treatment, in the PROSTQA Cohort.”
The other question is, if the USPSTF, Cochrane, and all the other rigorous evidence-based reviews recommend against widespread screening, why does the ACS come out with such an equivocal statement? “Discuss the risks and benefits for your individual situation with your doctor” is really a copout. If you’re supposed to be educating patients, then explain the risks and benefits for different situations right there in your statement. There are plenty of doctors out there who perform surgery indiscriminately. “If you don’t have surgery, there’s a chance, a small chance that you could die” is a sales pitch that most patients couldn’t resist. This parallels the situation in breast cancer screening. (Last week New York State governor Cuomo was promoting breast cancer screening for women 40 and over. Try to find a hint of the debate in this document. http://www.nyc.gov/html/doh/html/living/cancer-breast.shtml)
Here’s my favorite prostate cancer story. Note that this patient had a Gleason score of 6, which shouldn’t even be treated http://jco.ascopubs.org/content/30/35/4294.full It sounds like the guy got up off the gurney just before surgery and walked out.
http://www.nejm.org/doi/full/10.1056/NEJMcpc0707057
Case 15-2008 — A 55-Year-Old Man with an Elevated Prostate-Specific Antigen Level and Early-Stage Prostate Cancer
Michael J. Barry, M.D., Donald S. Kaufman, M.D., and Chin-Lee Wu, M.D., Ph.D.
N Engl J Med 2008; 358:2161-2168. May 15, 2008
DOI: 10.1056/NEJMcpc0707057
The patient was very frightened about the diagnosis of cancer and particularly concerned about loss of spontaneous erectile function…. He worked as a construction supervisor and lived with his girlfriend and her children.
[Long discussion about surgery vs. radiation.]
Dr. Kaufman: In 1996, the patient decided, after careful consideration of the options presented by Drs. Zietman and McDougal, to undergo radical prostatectomy. Six months after the biopsy, he was taken to the operating room, but he abruptly changed his mind and canceled the procedure. He has had continued problems with obstructive urinary symptoms and a large residual volume. The PSA level ranged between 3.6 and 6.6 ng per milliliter for the next 3 years. Three years after the diagnosis of prostate cancer, treatment with finasteride was begun because of obstructive symptoms; the PSA level ranged from 2.3 to 3.1 ng per milliliter for the next 5 years, until he stopped taking finasteride because of decreased libido. The most recent PSA level, measured 10 years after the initial diagnosis, was 5.2 ng per milliliter (Figure 2 Serum Levels of Prostate-Specific Antigen in This Patient over a Decade.). The patient feels well.
Thanks for this insightful comment. Any time people hear “cancer” it’s scary; I hope that we journalists can do a good job of educating them to consider all options and that while opinions on testing and surgery vary, there is no one “right” decision — it has to be up to the individual and his practitioner.