There is considerable controversy over prostate cancer screening and the appropriate approach for the newly diagnosed patient. As a medical oncologist specializing in prostate cancer – and a prostate cancer survivor – I am absolutely convinced of the value of screening using the PSA test (for absolute value, as well as year-to-year changes) and digital rectal examination, to guide which men should be biopsied.
The age-adjusted prostate cancer death rate was rising every year and peaked in 1991. But upon introduction of PSA (prostate-specific antigen) screening, prostate cancer mortality has declined for 20 consecutive years, and by almost 40 percent. It is doubtful any development in therapy can alter mortality to the extent early detection and treatment could.
Prior to PSA screening, about 40 percent of men diagnosed with prostate cancer already had metastatic disease, usually painfully in-bone. The rate of metastatic disease at diagnosis now is about 4 percent. Most of those men have not been screened on a regular basis.
PSA screening has led to more cases being diagnosed, making prostate cancer the No. 1 cancer diagnosis in men in the U.S. Because PSA allows for early detection, patients with localized prostate cancer also have smaller amounts of cancer than was seen in the pre-PSA era.
It is true that many cancers diagnosed are of the low-risk variety, and may not need or benefit from surgery or radiation. However, 50,000 men are diagnosed with high-risk prostate cancer annually and are at a significant risk of eventually dying from the disease.
I hope that our primary care physicians, who are in a position to do the screening, do not forgo screening. If they do, oncologists like me, who deal with advanced prostate cancer, will be extremely busy in the future.
Former state Sen. Eddie Goodall’s suggested approach, in an article on these pages, that every man newly diagnosed with prostate cancer receive honest data regarding personal risk of morbidity and mortality, as well as a statement of personally appropriate options and risks, including active surveillance (i.e. the chance that his cancer may progress to an incurable stage and potential risks of repeat biopsy, such as infection and bleeding) is a reasonable approach to counseling newly diagnosed men, especially men with low-risk cancers, many of which are not likely to result in death.
Like Goodall, I was diagnosed with prostate cancer a young age, in my case 53. My PSA which had gone from 2.6 to 3.9 in one year, a normal digital rectal exam, and on biopsy a single focus of adenocarcinoma with a Gleason score of 6 (3+3) in one of 12 biopsy cores. I was fully aware of the risks of incontinence and loss of erectile function that can occur as a result of prostatectomy, but chose surgery for several reasons.
No imaging test can show the true extent of cancer in the prostate; only a pathologist can determine this by examination of the entire gland, seminal vesicles and lymph nodes. Radiation can be very effective. There are however, long-term risks, including second cancers in the bladder and rectum. Those risks for me would begin in my 70s if I had radiation at age 53.
I did not see the practicality of following the PSA, regular digital rectal exams and perhaps multiple repeat biopsies for 10, 20 or 30 years. Post-prostatectomy, following the PSA is an excellent means of knowing whether your surgery is successful. The PSA should remain undetectable. Mine has been undetectable, with a PSA of less than 0.01, with the ultrasensitive assay, ever since my surgery.
I did have low-risk cancer, only a 0.5 cm focus of cancer confined within the prostate capsule. The physiologic functions that were lost immediately after surgery have recovered.
I would have been an excellent candidate for active surveillance. However, I am very happy with my outcome with surgery. The best part is that it appears now, 10 years later, that I will never have to worry ever again about having prostate cancer, the cancer that killed my grandfather at age 77.
Eddie Goodall chose active surveillance, contrary to the advice of his physicians. I wish him well with that approach. Most physicians agree that a patient with low-risk, low-volume cancer is a candidate for active surveillance. There are tools and resources for patients to help better understand disease risk and appropriate options. Links to these resources can be found at www.pccnc.org/navigation.shtml
William R. Berry, M.D., of Cancer Centers of North Carolina in Raleigh, serves as associate chairman of the Genito-Urinary Cancer Research Committee of US Oncology, a 900-member network of oncologists.