A media release issued yesterday by Dr. David Samadi, a specialist in minimally invasive surgery at Mount Sinai Medical Center in New York City, has questioned whether the purpose of prostate cancer screening is to save lives or to prevent progressive prostate cancer.
Dr. Samadi was responding specifically to media commentary around the data from the Norrkoping screening study (which we had also discussed in some detail).
Now the epidemiologists are going to take issue with this suggestion. They will argue that the whole idea behind screening for any disease is to lower the disease-specific mortality rate, and that without such an outcome, screening is not efficacious. However, … Dr. Samadi does raise an interesting question, because if you consider screening for prostate cancer as a tool to prevent the risks associated with progressive disease (most especially the risk of metastatic disease), then screening for prostate cancer starts to look a whole lot more effective than if you only consider the impact on prostate cancer-specific mortality.
The “New” Prostate Cancer InfoLink has no intention of taking sides on this discussion. This is going to be an intellectual argument between the epidemiology community and the clinical treatment community, and if we are going to change the definition of “screening” such that it has new study endpoints than the traditional one of mortality, then the implications for medicine may be massive. The one thing that we will say is that it may be a discussion whose time has come. If that is the case, then new endpoints for screening studies (in more than just prostate cancer) will be needed.
One way to think about this relates to screening for a disease like HIV. In the beginning, people were getting tested with the goal of saving lives by prevention of the end stage of HIV … .i.e., AIDS. Today, however, most HIV screening is being done with the goal of preventing transmission of HIV. This still impacts the survival of people diagnosed with HIV, because they can get appropriate treatment early in their disease, but it is also helping to prevent many men and women from getting HIV in the first place because people who know they are HIV-positive are reasonably likely to ensure safer sexual parctices than those who believe they are HIV-free.
In the case of prostate cancer, Dr. Samadi is basically arguing that we know how to prevent most cases of early stage prostate cancer progressing to later stage disease. And this is certainly true. Whether the consequences of early stage treatment are “worth” the benefit in the majority of men getting treated is a much harder question to resolve … and that is where the potential benefits of active surveillance for men with low- and very low-risk disease and life expectancies of less than 15 and less than 20 years, respectively, start to come into play.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk | Tagged: Diagnosis, outcome, risk, screening, Treatment, tyesting |
THE "NEW" PROSTATE CANCER INFOLINK 
Reducing morbidity and mortality are both acceptable outcomes but it becomes extremely difficult because the harms of the disease must be balanced against the harms of the interventions. That then requires determining QALYs (quality-adjusted life years). That is very complicated because it involves assigning some fraction to each health state such as having impotence, incontinence, etc., for x number of years vs. the QALY of living with metastatic disease.
This is, indeed, a new way to frame the argument. It also proposes that the argument that PSA screening (testing) saves lives is a failed argument. Instead of two sides of the debate we can now have four sides.
The article in question says in part that, “In addition to being the second leading cause of cancer death in men, prostate cancer can result in serious health problems in men who might die from other causes,” and Dr. Samadi suggests that early detection and treatment will avoid these serious health problems.
One of my health concerns is a heart condition — cardiomyopathy. I have what might be termed “early stage” cardiomyopathy. Later stages of this condition can indeed cause more serious health conditions than those I cope with now.
One of the therapies for cardiomyopathy is a heart transplant. I have yet to hear a suggestion (or read one on the Internet from an eminent cardiologist) that I should have a heart transplant now to avoid the potential serious health problems that might develop.
Another condition is arthritis in my knee joints — again “early stage” but no doubt (unless the condition is “cured” by my cardiomyopathy or my prostate cancer carrying me off) this condition may develop and give rise to serious health problems. No one has yet suggested that early amputation of the limbs would help me avoid these potential problems.
A most amusing man who posted by the name of Mac (who was a surgeon by trade and opted for proton beam therapy in 1996, long before it was fashionable to do so) suggested in a post that the only sure cure for prostate cancer would be to remove the prostates from pre-pubescent boys.
This suggestion of Dr Samadi is equally laughable in my opinion.
Oh! And in passing … Prostate cancer is not the second leading cause of cancer death in all men — only in men over the age of 80. Wonder why all press releases keep using the incorrect statement? Could it be partly to influence the crowd?
H. L. Mencken is quoted as saying, “The whole aim of practical politics is to keep the populace alarmed — and hence clamorous to be led to safety — by menacing it with an endless series of hobgoblins, all of them imaginary.” Does this apply to the prostate cancer industry too? Hmmm … ????
Apart from routine annual PSA screening to avoid ultimate outcomes such as death or metastasis, clinicians need to consider another outcome that may make such screenings worthwhile: the possibility of incurring physical harm or emotional pain. In other words despite treatment risks, PSA screening and follow-up biopsies make sense in order to rule out extreme concern about contracting cancer.
In my mind routine annual screening can be justified to eliminate needless anxiety. Severe anxiety can arise even among the most informed patients when they do not know if they have prostate cancer and if so, at what stage (ranging from indolent, to low, to moderate to advanced). Once even low-grade cancer (Gleason 2 to 6) is confirmed, anxiety can become quite rampant if a patient and his physician decide not to go the route of invasive treatment, and instead choose active surveillance. Such anxiety is not unwarranted since for now there is no definitive biomarker that can determine which early-stage prostate cancers are likely to become aggressive.
Terry, cute, but you’re comparing apples to oranges.
Dr. Samadi makes a good point, but why not accept both benefits — enhancing the likelihood of cure, but also adding to years of life that are free of progression and late-stage disease? I personally appreciate the latter benefit for my own case that is very likely incurable with current technology.
I found it a little amusing that the only advance in treatment highlighted by Dr. Samadi, a surgeon, was the surgical advance in robotic therapy. I’m wondering if he is aware of the sea change in external beam radiation therapy results after the doses were escalated upward to around 80 Gy. I’m wondering if he is aware that brachytherapy at centers of excellence is posting rates of apparently curative success within a few percent of perfect, with quite long-term follow-up and virtual flat-lining of success at those levels, results which surgeons should envy. Brachy, or brachy/EBRT combos, is even showing robust and high success rates for intermediate-risk patients, with even high-risk patients doing better than many of us would have expected a few years ago.