THE "NEW" PROSTATE CANCER INFOLINK

One would normally expect Susan B. Komen for the Cure to be an ardent supporter of cancer screening — in the interests of women at risk for breast cancer … but they are the providers of an article just published in Readers Digest entitled, “Cancer Screening: Doing More Harm than Good?” What is going on?

The article, actually written by Sharon Brownlee, makes a number of important points that are well worth understanding about cancer screening tests:

• Only the Pap smear test (used to screen women for risk of cervical cancer) has ever been shown to have a dramatic impact on a patient’s risk of dying from the cancer being screened for. … Between 1955 and 1992, according to the American Cancer Society, Pap smears cut the death rate for cervical cancer by 74 percent.
• Screening tests for breast cancer and colon cancer don’t have anything like the impact on the risk of dying from these diseases that either patients or their doctors tend to assume (for breast cancer, mammography may reduce the risk of dying from breast cancer by 15 percent for a 60-year-old woman; for colon cancer there are actually no data confirming that screening with fecal blood monitoring and a follow-up colonoscopy reduces the risk of death because that study is only now being done as part of the PCLO trial).
• We all probably know that there are no data from randomized trials confirming that PSA screening reduces the risk of death from prostate cancer.

Here are a couple of other facts that the article (surprisingly) does not make — at least, not explicitly — but which are nontheless true:

• Our ability to detect cancers like breast, colon, and prostate cancer now massively outperforms our ability to treat them effectively and at no other risk to the patient.
• Our ability to differentiate or tell the difference between aggressive and non-aggressive forms of cancer before we start to treat them is nearly non-existent!

What does this all mean? Perhaps a better question is, “What does all this not mean?”

• It does not mean that getting tested for certain types of cancer is a “bad” idea.
• It does not mean that women shouldn’t get mammograms (or that men shouldn’t get PSA tests).
• It does mean, however, that the step that comes after that initial screening test is a lot more complicated than we tend to appreciate.

If you don’t have screening tests that you need, you will not know that you are at risk, so you can’t make the best possible decision about the actions you need to take.

For most people in America today, any diagnosis of cancer or even the diagnosis of risk for cancer is most likely to relate to an early stage and potentially low risk form of that cancer (prostate cancer specifically included). Therefore, what needs to done about it deserves thought on the part of the patient, careful discussion between the patient and his/her doctor, and a very real appreciation of the risks associated with treatment.

Patients who do not understand this and who rush to treatment without taking a pause to learn what can come next and what they may be getting into are like people who decide to go bungee-jumping without making sure they have double- and treble-checked the security of that rope around their ankles. … They are kinda missing a crucial step along the way!

In the case of prostate cancer we can give you a specific and understandable scenario.

From about 1992 until relatively recently the recommended response of most specialists to an elevated PSA or a “positive” physical examination (a DRE) has been “Get a biopsy.” If the biopsy was positive, the next recommendation was “Cut it out” (or “Radiate it” or whatever). Today, we are just beginning to understand that there may be at least three other good options following a positive biopsy if the patient clearly has early stage, low risk disease:

• Treat only the part of the prostate that clearly has cancer (with cryotherapy or with high-intensity focused ultrasound) — if that is possible with a high degree probability
• Use dutasteride or finasteride (a 5α-reductase inhibitor) as systemic therapy to prevent or at least significantly delay progression
• Use active surveillance (or even watchful waiting if you are old enough) and monitor the cancer before you decide what to do, because you may not ever have to do anything more

None of these three forms of management has been “proven” to have a definitively valuable long-term outcome in appropriately selected groups of patients (yet). Even so, they are all in clinical use. And when executed properly they all come with lower risks to the patient than whole gland removal (surgery) or whole gland radiation.

As always … Caveat emptor!

Filed under: Diagnosis, Management, Risk Tagged: | Diagnosis, risk, screening