Prostate Cancer: The Dilemma of Diagnostic Testing
By Scott D. Perrapato
Prostate cancer remains the most common cancer men over 50 have to deal with in their lives. More men will die due to prostate cancer than any other cancer, except for lung cancer (which is declining in men as more men stop cigarette smoking!). The same is true for the number of women who succumb to breast cancer each year.
Advanced prostate cancer can be controlled for many years, but not without a decreased quality of life and direct side effects due to androgen deprivation (“hormonal”) and other systemic therapies.
It is estimated that one-third of all prostate cancers in men will have a direct and adverse effect on their lives. So, how do you find prostate cancer early enough to cure it? In May, the U.S Preventive Services Task Force concluded that solely relying on random blood test screening (Prostate Specific Antigen, PSA) is not reliable for detecting prostate cancer and has more risks than benefits. In fact, the routine testing subjected many men, who did not have prostate cancer, to procedures and psychological stress. This is true if we look at just the PSA blood test as there is no “perfect” test for diagnosing prostate cancer. Women and their health care providers face the same dilemma with mammograms and breast cancer diagnosis.
However, using a combination of family and personal history (genetic risk), the PSA blood test (which includes monitoring over time and other PSA analyses) and a thorough physical examination (digital rectal examination, DRE), we and many groups have proven that fewer men need to undergo even minimally invasive prostate biopsy techniques to find clinically significant prostate cancer (cancer that would most probably impact a man’s life). We also now know that one-third of men with prostate cancer have a predictably slow growing type that can be managed very safely with active surveillance (“watchful waiting”) and therapy can be initiated at the appropriate time, often years after diagnosis.
The European Randomized Study of Screening for Prostate Cancer (ERSPC) indicates that early detection of prostate cancer by a combination of these checkups has yielded a 21 percent reduction in the risk of death from prostate cancer! That is incredibly good news.
The curative therapies for men with prostate cancer, including external radiotherapy, brachytherapy (placing radioactive seeds into the prostate gland), laparoscopic robotic prostate surgery, cryotherapy (freezing the prostate gland) and high frequency prostate gland ultrasound treatment, continue to become more refined with fewer side effects.
A common sense recommendation would be that men in good health who have a significant family history of prostate cancer or a concern about prostate cancer should contact their health care provider to discuss the general risk and benefits for early detection screenings. If desired, setup an annual program of personal risk assessment, physical examination and judicious PSA blood testing and analysis.
Scott D. Perrapato, DO, FACOS, is a urologist and urologic oncologist at Fletcher Allen and an associate professor at the University of Vermont College of Medicine.