Recently, the New England Journal of Medicine released online early findings from a pair of long-term medical research studies. The results of the studies, Mortality Results from a Randomized Prostate-Cancer Screening Trial and Screening and Prostate-Cancer Mortality in a Randomized European Study, provide new information and have resurrected old questions in the ongoing medical community debate regarding the wisdom of conducting mass screening for prostate cancer.
One study indicated that there was very little difference between the control group and the screening group, that the overall rate of death from prostate cancer was low, and that the benefits of prostate cancer screening does not outweigh the risk. The other study found that screening for prostate cancer reduced prostate cancer death by 20%. There are complaints about the manner in which both studies were conducted. But the biggest problem is that neither study addresses the real issue.
Prostate cancer screening generally first involves a diagnostic test called the digital rectal exam (DRE) in which the healthcare provider accesses the prostate manually, using a finger to check for irregularities. The second part of the screening is a simple blood test to assess the level of prostate-specific antigen (PSA). High blood levels of PSA may indicate cancer.
Both tests are normally performed in your healthcare provider's office, and have virtually no side effects. So why all the fuss? How could the benefit of these tests possibly fail to outweigh the risks when the risk is nonexistent? The answer is that they don't. The tests do exactly what they are designed to do, without risk to the patient.
The DRE and PSA are being blamed for the side effects caused by invasive diagnostic tests and aggressive treatment for prostate cancer, the theory being that in addition to the aggressive, dangerous prostate cancers, these tests identify cancers for which treatment may not have been necessary.
Because it can be difficult to tell the difference between a slow-growing cancer that may not need treatment and an early stage aggressive cancer that does, doctors tend to treat all identified cancers as if they are aggressive. This means ordering prostate biopsies, which are painful, require anesthesia, and carry the risk of infection, bleeding and urinary problems; and selecting one or more of the standard cancer treatments-- radiation, chemotherapy and surgery--and the substantial risks and side effects that each method of treatment entails.
The thinking in the medical community seems to be that if the cancers aren't identified in the first place, they won't be treated and the patient won't be at risk of potentially life-altering side effects, such as incontinence and impotence. Some patients would die from the absence of treatment, but not enough to substantially change the overall rate of death from prostate cancer.
That's all fine and good...unless you're one of the dead guys.
The medical community is throwing the baby out with the bathwater here. The problem isn't with the risk-free, minimally invasive diagnostic DRE and PSA tests; these are valuable and essential tools to assist providers in diagnosing prostate cancer.
The problem lies in the lack of diagnostic tools to differentiate between less harmful cancers and dangerous, fast-growing cancers. The problem lies with the healthcare providers who don't attempt to use their clinical skills or reason to differentiate between possibly harmful and definitely harmful cancers, opting instead to immediately and aggressively treat all signs of cancer, without regard for quality of life. And the problem lies with patients too frightened, shocked or apathetic to ask questions of their providers, fully understand their condition and options for diagnostic tests and treaments, and actively participate in their care.
Obviously, better diagnostic tests with minimal side effects need to be developed. Unfortunately, that kind of medical development takes time. Long term, tightly controlled studies need to be initiated to determine whether a specific PSA level can accurately predict an aggressive cancer, eliminating unnecessary invasive procedures for cancers that are unlikely to cause problems.
In the meantime, the best solution is probably for providers to just rely on their diagnostic skills and exercise some self control. You don't need to biopsy every guy with a slightly elevated PSA. Learn to watch and wait and retest. Also remember to educate your patients about avoiding certain PSA-elevating behaviors (sexual activity and masturbation with ejaculation) for a few days prior to the test, and ask about those behaviors if the PSA is elevated.
Patients need to help out too, by being active participants in their own care. Ask questions, get additional opinions, and consider refusing tests and treatments that have not been sufficiently explained or that don't make sense. Use reputable sources to educate yourself on treatment options, side effects and statistics.
If you have risk factors for prostate cancer, ensure that your healthcare provider screens you regularly beginning at age 40. Cancer won't go away just because it hasn't been diagnosed. It remains in your body even if you attempt to pretend that cancer can't possibly be there. Waiting to be tested just gives cancer a nice headstart for total body domination.
Incontinence and impotence are certainly not desirable conditions, but then again, neither is death. Dying is pretty much the worst result of all, though I suppose it has its advantages. You won't have to worry about impotence, but I sincerely doubt that you can have much fun with an erection when you're dead.
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Farleftside
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Comments
Thanks for reading.
This is an issue that hits close to home, so the misrepresentation of facts and the outrageous recommendation against screening makes my head spin.
I'm really hoping that this gets as much attention as the anti-screening post did, or that someone in the mainstream offers a logical counterpoint to the story, just to get the information out there. Without prostate screening, my uncle would have died; I don't think that anyone should be at risk for death because they were misinformed.
Thanks for reading, and thank you for your support.
Your serious article appears as if You have skills in Primary Health Care.
I'm bashful talking and asking questions about certain Serious Health Topics.
Oh, a Prostrate.
I heard, normal.
~
If the VAMC ask to do a renal prostrate exam, I usually decline the simple rubber glove test method. It tickles. My Physician is great.
She's good. I ask:`You don't like to do that, do You? Please, my good VAMC physician, tell me the darn honest truth? You would want the exam done to You?
Then we talk of bowels.
In India they ask Guest:`
How was your evacuation?
They get you Flax Oil & Seneca,
and then the VAMC gives Fecal test?
O, Polyps? None. Colorectal Cancer?
I don't think I have colon cancer today.
huh.
A SIGMOIDOSCOPY is not a COLONOSCOPY?
The VAMC has a honor system basket filled full.
O, 'um give 3- free Trojan-ENZ brand condoms.
O, they are lubricated. I give to the Mennonites.
Oh, what wonderful neighbors. No breed bunny.
According to VAMC medical records:`Oops. Oy!
I never send via postal mail the fecal occult card.
I disregard a Health test. I avoid rubbers/gloves.
It just don't seem normal. I wear blue goulashes.
I no like to be tickled You know where, truthfully.
You give counsel. Serious Health Care Questions.
It's quirky of me? I read Thieves get a bad bowels.
Pillagers, kleptocratic thugs @ AIG will go rotten?
The creeps who pal with butt-sniffers get squirts?
O, when the rural mortician gets a dead Rich Elite?
I heard that's it's not a baby pacifiers that is stuffed.
The old time geezer at the funeral parlor used a beet.
They steal billions. Merrill Lynch ilk may be lynched?
I read that a hanged man will have a Last Erection. Oy!
It's true about war carnage. A dead soldier mid-finger?
Maybe it's the killed one's Last Expression. AIG decay!
The article you wrote is well written. I No trivialize this.
I'm sure the questions will be Heath Care issue, Helpful.
Despite not being a Republican, I sometimes do seep and spew. I try not to do it in public, but I have a tissue for when I do.
I do have skills in primary care. Also family medicine, geriatrics, long term care, short term rehab, etc., etc.
Unfortunately, men are not the only ones who must endure the rectal exam; women generally have theirs done annually, along with a Pap. I wouldn't say it tickles. ;) I admit, I sometimes refuse.
I appreciate the euphemism, and may borrow it. It's more appropriate than "bowel movement", as bowels move continually. My Sigoth refers to his evacuation as "taking a meeting".
A sigmoidoscopy is kind of like a mini colonoscopy. The difference is about three feet, a lot of drugs, and spending a few hours looking as though you've been hit by a truck.
I hope the Mennonites enjoy the gift, and you enjoy the quiet.
Few people do send back the fecal occult cards. They should really be done in the office. There's just something distasteful about sending one's poo through the mail.
I'm not sure quirky is the word I would use. Unconventional, certainly. But quirky if you like.
We can certainly hope that the crooks at AIG get the backdoor trots. I'm sure there's a way to make it happen, like a box of gift-wrapped Ex-Lax brownies with their million dollar bonus checks.
I confess that I'm not sure I want to know what goes on behind closed doors at the funeral parlor.
I believe there is a last erection.
Whatever your motivation, I enjoyed your comment and thank you for reading.
and this gets distributed to a VAMC.
I tease ref:`Drink. I'll share at a AA.
I honestly am a believer in sobriety.
I'll share at the Vet Group Gathering.
I do mind. I try to care.
Can a cold beer hurt us?
DC's elites gulp cheap wine.
AIG sip Morgan Morticians.
Thieves will be DOD's stiffs.
Yes. My intent was sincere.
Maybe I'll tell all to sip H20.
I miss Hawaii too. O, Howdy.
I know someone there. Thanks.
Prostate cancer is usually slow-growing in men 75 and older. At this age, it generally takes 10-15 years for the cancer to become problematic. Based on the average life expectancy in the US, it is assusmed that most men of this age suffering from prostate cancer will die of other causes, so it doesn't make much sense to treat them unless they develop troubling symptoms. For this reason, the major cancer organizations are now recommending against PSA screening for men 75 and older.
In younger men, the cancer may be slow growing, or may be a faster growing, more aggressive cancer. It is difficult to tell--even from a biopsy--which type the cancer is. None of the diagnostic tests we currently have, nor the Gleason scale (used by pathologists to examine and grade biopsy tissue and assign a score that can help predict whether the cancer is aggressively malignant) are anywhere near foolproof.
Doctors tend to follow established protocols when treating a patient (e.g. If A is true, then we must do B). The facilities they work for prefer it, and it's safer in terms of liability and lawsuits to stick to the established program, because that is easier to defend in court later.
Doctors also tend to err on the side of caution. Rather than risk missing an aggressive cancer, they throw everything they've got at every cancer.
No prostate cancer is an emergency. Aggressive or not, the patient has enough time to ask questions, seek additional opinions, and research unanswered questions (hopefully using reputable sources) before agreeing or refusing invasive testing or treatments.
There is a course of treatment informally called, "watch and wait", "watchful waiting", or "active surveillance". This generally involves men who have low elevated PSA, have already had a biopsy and have been assigned a low or fairly low Gleason score. The PSA level is closely monitored; an increase in PSA may mean that the cancer is growing.
Watchful waiting is gaining in popularity. It is especially beneficial for men over 65 who have low PSA levels and low Gleason scores. However, there is some debate about the wisdom of using this protocol for younger men. Some docs think it's ok; other docs strongly recommend treatment for younger men. This is most likely because a man diagnosed with a slow growing prostate cancer at age 40 may start to have serious symptoms around age 50-55. If the cancer is likely to require treatment during the average male life span, it's probably best to have it early, while the body is stronger and better equipped to handle the extreme fatigue, etc., that often accompanies chemotherapy, radiation and surgery.
I believe there are ongoing studies searching for the presence of a genetic marker for prostate cancer (I'll try to locate my source on this and re-post), but it's not likely that a test will be developed anytime soon, since such a marker may not exist. I believe I came across studies of some other research groups working to develop better diagnostic tools as well; I'll try to locate those, too.
We also need PSA screening studies that apply to specific groups. The age range needs to be smaller in order to more accurately identify trends that could be of diagnostic use. We also need to study groups of men with the same risk factors; along with age, groups of men with risk factors such as race, ethnicity and family history each need to be studied.
I think that one of the best ways to combat aggressive and possibly unnecessary treatment is for the major cancer institutes to embrace active surveillance, develop a formal protocol and begin a campaign of provider education. Providers (and now the media, and soon, the public) need to stop blaming excessive treatment on an important diagnostic tool, and accept the introduction of a system that accurately weighs benefit versus risk.
The most effective way for a patient to ensure that he doesn't get tests or treatments that he doesn't need is to ask questions, seek additional opinions, arm himself with knowledge about his condition, tests and treatment options and exercise his right to refuse any test or treatment that he feels are not in his best interests.
I hope I answered your questions, and apologize for the length. I'm glad you asked the questions you did; in answering, I realized that there's a lot of useful information scattered around. I may try to consolidate at least some of it here for easier access; if I do, it's because of you.
Thanks for reading! I'm looking forward to your next post; you give us a laugh when many of us desperately need one.
The bottom line with the PSA test is it picks up 49 cancers that will NOT kill the patient for every one it finds with WILL kill the patient. Of the forty nine who are treated unnecessarily, half will become impotent, and a third incontinent. Radiation treatment adds the possibility of bowel problems (diarrhea).
This is not to say that an informed patient should not get the biopsy. He should just understand the above!
For more, see my blog post at http://open.salon.com/blog/russpalmeri/
and thanks for your comments!
Thanks for commenting.
No one will ever definitively know who should or shouldn't be biopsied for elevated PSA levels until studies more specific to age group are done. The studies linked involve far too wide a range to add much knowledge. Additionally, I find it hard to believe that none of the men in the study had any risk factors, especially considering that age itself is a risk factor. So we need studies specific to risk factor as well.
Both studies have problems, including the one that found that testing reduced prostate cancer mortality by 20%. This is why the major cancer institutes are recommending further study before we make substantial changes to the way we screen, and why it's dangerous to cling to those statistics you cited. Until those stats are reproducible in further studies (ongoing now, so it shouldn't be much longer), we really need to continue to screen.
My concern is that men who need to be screened won't be, and I'm speaking here about men with risk factors. I think that all providers should ensure that their male patients who have reached age 50 should have a DRE yearly, and that men with risk factors should be screened with both a DRE and PSA level starting at age 40. The providers should absolutely give their patients data regarding the uncertain nature of prostate cancer, screenings and diagnostic tests in order for those patients to be fully prepared to make the call as to whether they want more invasive testing for an elevated PSA.
We need to take responsibility upon ourselves, both provider and patient. What we cannot do is blame a simple, useful, diagnostic test, as it is the patients and providers who decide on a course of action, not the PSA.
We need to take responsibility upon ourselves, both provider and patient. What we cannot do is blame a simple, useful, diagnostic test, as it is the patients and providers who decide on a course of action, not the PSA.
[SNIP]
The point is if the test finds 50 men that will be treated to save one, and leaves the majority of the remainder either impotent, incontinent or both, then is it indeed useful? It may have a place in heath care, but that place is yet to be determined.
Also, you are being naive when you say it is up to the providers and the patients to make the decision. Providers provide. That's what they do. They are NOT going to see a patient that has cancer be untreated. Nor will patients with cancer be comfortable forgoing treatment. They may do so, but I can tell you their quality of life will not be great- they will constantly be worried about their cancer.
In an ideal world, the doctor will have a thorough and complete discussion of all these facts, and in concert with an informed patient, a decision will be made. This is not an ideal world, and if the PSA is done, many many men will be unnecessarily treated.
It is also not correct that masturbation or ejaculation will alter the PSA test. This is old data, recent studies do not confirm this (according to my urologist).
The PSA test is not ready for prime time, as you yourself admit. If it can't tell the difference between cancers that matter and those that don't, it is causing more harm than good.
The PSA test does not kill anyone, nor does it render them incontinent or impotent. The PSA is just a simple blood test that is a valuable diagnostic tool. The problem is the providers who recommend agressive treatment for everyone, rather than use their medical knowledge to determine the best course of action, and exercise some self-control.
Patients and families can help themselves by learning about prostate cancer and prostate cancer screenings. Don't be afraid to ask questions about your results, don't be afraid to seek another opinion, don't be afraid to take some time to inform yourself before making any treatment decisions. Above all, don't be afraid to have the test.