Over the last year recommendations have changed for screening and treating some of the most prevalent diseases in America, often after intense public and professional debate. Prostate cancer is one of those diseases.
For years, men 40 and older were told to undergo annual prostate cancer screening, including a blood test that measures prostate-specific antigen (PSA), a protein produced by the prostate gland. Elevated PSA levels may indicate prostate cancer, although there could be other explanations.
Dr. Gerald Andriole, urologic surgery chief and director of the Men’s Health Center for Washington University Physicians, is also leading prostate screening research. He is lead author of a study published last spring in the New England Journal of Medicine that presents results from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial.
From 1993 to 2001, researchers followed 76,693 men at 10 U.S. study sites. The researchers concluded that, “the rate of death from prostate cancer was very low and did not differ significantly” between men who were screened annually and those who were not. Andriole notes that researchers continue to follow the subjects, and future results may be different.
“For every 1,400 men who get screened, about 225 get a biopsy, and about 48 are found to have cancer,” Andriole says. “We treat all 48, but we have found that after 10 to 13 years of follow up, only one man is saved. And this is why we have to rethink screening. We have to acknowledge that when we screen, we overdiagnose prostate cancer. So 48 men are treated, and only one man benefits.”
Treatment involves risks and costs that could be avoided if physicians knew which patients would benefit from treatment. “We need to better characterize the type of prostate cancer,” Andriole says. “When we can look at cancer cells and determine which genes are activated, we’ll know which cancers grow very slowly and which are genetically coded to be more aggressive. We’re close to finally getting a big pay-off from all the genetics and genomics work of the last 15 years.”
While researchers continue their work, however, patients are left to wonder what’s best. “It’s confusing, and the American Urological Association has a long list of guidelines,” says Dr. Luis Anglo, a urologic surgeon at St. John’s Mercy David C. Pratt Cancer Center. “As a result, we’re individualizing screening recommendations.”
Most 40-year-old men should have a baseline PSA test and discuss their risk factors with their physician, Anglo says. “If the PSA is low, which it should be for a healthy 40-year-old, we may determine that the overall risk is low and choose to screen less often.”
For those patients at higher risk, there were developments this year in the field of prostate cancer prevention. “The REDUCE trial was published, which showed promising data using Avodart to prevent prostate cancer in men at higher risk,” says Dr. Salim Hawatmeh, a urologist with South County Urological.
Surgical treatment options also continue to expand. A ‘male lumpectomy’ is being developed, eradicating only the cancer rather than removing the entire gland. Currently, surgeons remove the prostate via several types of procedures, including a minimally-invasive, robot-assisted surgery. “Surgeon experience and understanding of prostate cancer surgery are key to the robotic approach,” Hawatmeh notes.
Like his colleagues, Hawatmeh agrees that more individualized treaments are needed. “One day we hope to have better prognostic information about prostate cancer in order to make optimal treatment decisions.”