Jane Brody is an experienced journalist who writes regularly about issues related to health care in The New York Times. Your sitemaster regularly reads her columns because she does her homework with care and provides sound information for her readers.
In the past couple of weeks, Ms. Brody has written two articles on prostate cancer in The New York Times:
- The first — from February 24 — deals with the value of “screening” for risk of prostate cancer (see “Debating the value of PSA prostate screening“).
- The second — from March 2 — deals with the application of active surveillance in the management of lower-risk forms of prostate cancer (see “Before prostate surgery, consider ‘active surveillance’” ).
Both of these articles provide good introductions to important perspectives on testing for and management of prostate cancer and particularly low-risk forms of the condition.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk | Tagged: active, Brody, New York Times, screening, surveillance |
THE "NEW" PROSTATE CANCER INFOLINK 
A PSA TEST IS CRUCIAL FOR MEN OVER 50. ONCE YOU HAVE A READING BETWEEN 2-4.0, YOU CAN ADOPT “WATCHFUL WAITING”. A CONSISTENT READING ABOVE 4.0 SIGNALS A BIOPSY MAY BE REQUIRED. IF YOUR GLEASON SCORE IS 7 OR ABOVE, YOU MAY NEED TO HAVE A) A RADICAL PROSTATECTOMY, B) A LAPROSCOPIC PROSTATECTOMY, 3) RADIATION TREATMENT, 4) HORMONE TREATMENT, AND A FOLLOW-UP PSA TEST EVERY 6 MONTHS TO A YEAR, FOR 5 YEARS.
Unfortunately there are so many errors in this comment from Dr. Hill that all it does is prove that having a PhD in something doesn’t make you an expert in something else. We strongly advise readers to do their own very careful analysis of the available information as opposed to following this erroneous guidance.
At the most basic level, (a) a man can have an aggressive form of prostate cancer than needs immediate treatment even though his PSA level is < 4.0 ng/ml, and (b) there are many men with Gleason 3 + 4 = 7 forms of prostate cancer who can remain on active surveillance, with no treatment whatsoever, for years (and sometimes for decades).
While many of us appreciate the publicity for PSA and the active surveillance protocol, not to mention the profile on our good friend Howard Wolinsky, the level of accuracy and research in Jane Brody’s article are not as thorough as usual. Here are just a couple of issues:
(1) The level of progression for men on AS is quite a bit higher than 5-10%; probably around 30-33% per the UCSF and Sunnybrook cohorts.
(2) Gleason 3 + 4 should not be considered low risk disease; anytime there is a 4 in the Gleason score, there is risk. Even 3 with a little 4 is still intermediate risk … albeit AS may still be appropriate.
I have blogged several more issues — you’ll find the post here
Dear Rick:
Respectfully, I think you need to go back and look more carefully at Jane Brody’s articles.
First, she never says that the level of progression for men on AS is 5 to 10%. She quotes Scott Eggener as stating that the level of progression is “5 percent annually for the first five to 10 years.” That’s much more that 5 or 10% over a 10-year period.
Second, she never states that Gleason 3 + 4 = 7 is “low risk”. She states clearly that “a composite score of less than 7 is generally deemed low-risk disease” and later that “A pattern 3 has no ability to metastasize, but a 4 is aggressive, Dr. Klotz explained. Thus, a Gleason score of 3 plus 4 is considered less aggressive than 4 plus 3.”
I humbly ask for your identification of “so many errors” and find your analysis insulting. I have been the President and Chapter founder of a men’s support group for over 15 years, and an often seminar presenter on PSA, brachytherapy, Gleason scores, radiation, radical and endoscopic surgery, and partner psycho-social engagement. The PhD has nothing to do with it. You are definitely not the “master” of sites.
Dear Dr. Hill:
Equally respectfully, since you asked:
1. You wrote that a PSA test “is essential” for men over 50 years of age. Bluntly, that is not true. It may be “advisable” for a great many men, but it is not “essential”. Furthermore, for many African American men it would be advisable to get an initial PSA level taken at more like 40 years of age since African American males are — on average — at much higher risk for prostate cancer and prostate cancer-specific mortality than the average Caucasian or Hispanic male.
2. You wrote that, “Once you have a [PSA] reading between [2.0 and 4.0 ng/ml], you can adopt “watchful waiting”. In the first place, there are men who can be diagnosed with aggressive forms of prostate cancer with PSA levels way below 4.0 ng/ml, and even some when their PSA is < 2.0 ng/ml. All that a PSA test can do is give you some preliminary idea of the possibility of risk for any one of several prostate disorders. Every patient at potential risk for prostate cancer needs to have be carefully assessed with respect to other factors beyond his PSA level. Secondly, a man with a slightly elevated PSA level of between (say) 2.5 and 5.0 ng/ml would be wise to get that PSA test repeated before he does anything else. It could just go down again. PSA levels can vary for all sorts of reasons — even just according to time of day. Thirdly, your use of the term "watchful waiting" is highly inappropriate in this situation. "Watchful waiting" as applied to prostate cancer is a very specific strategy for the management of men with advanced or metastatic prostate cancer who are likely to die of some other clinical condition (heart disease, diabetes, you name it) prior to any risk of them dying from their prostate cancer. The goal of "watchful waiting" is thus to avoid unnecessary treatment of such men until — if it is needed — it is being given with palliate intent to manage pain from bone metastases. This has nothing to do with men with low PSA levels!
3. You wrote that "A consistent [PSA] reading above 4.0 [ng/ml] signals a biopsy may be required. That may or may not be the case. It depends on several other factors. It would have been much more accurate to state that, "A consistent PSA level of 4.0 ng/ml or higher signals that further tests would probably be appropriate, potentially including a prostate biopsy."
4. You wrote that "If your Gleason score is 7 or above, you may need to have a) a radical prostatectomy, b) a laparoscopic prostatectomy, 3) radiation treatment, 4) hormone treatment, and a follow-up PSA test every 6 months to a year for 5 years." You apparently don't understand that: (a) Many men with Gleason scores of 7 (mostly 3 + 4 = 7, but inclusive of some with 4 + 3 = 7) can be successfully managed on active surveillance, sometimes for many years. (b) A laparoscopic prostatectomy is still a radical prostatectomy. It's just a radical prostatectomy carried out without the need for open surgery. (c) There are about five or six different ways, today, to give first-line radiation therapy to patients with clinically significant, localized prostate cancer. Just lumping these all together as "radiation treatment" is thoroughly misleading. (d) There are also multiple other ways to provide first-line treatment for men with relatively low risk forms of localized prostate cancer that you don't mention at all. At the 2018 AUA meeting in San Francisco there was a highly detailed presentation on about 13 different types of treatment that could reasonably be offered to a man with favorable, intermediate-risk, localized prostate cancer (although their relative effectiveness and safety was being carefully debated). (e) The use of androgen deprivation therapy (ADT, also known as "hormone" therapy) would be highly inappropriate as first-line therapy or even as part of first-line for any man with localized prostate cancer and anything other than high-risk or very high-risk prostate cancer. Lastly, after any form of first-line treatment for localized prostate cancer, patients should have their PSA monitored quarterly for at least a year and then every 6 months or annually for at least 5 years and arguably for as long as 10 years depending on the exact nature of their diagnosis.
Please visit the following sites: cancer.net, cancer.ca, cancer.org, cancer.gov, mayoclinic.org, and ncbi.nim.nih.gov, and then re-write your article. You have “cherry picked” where it is not necessary, and some of your comments are just wrong.
Dear Dr. Hill:
You are entitled to you opinion, but I happen to disagree with you … strongly. The sites you are referring to provide only the most basic of information. Have a look at the latest updates to the NCCN guidelines on the diagnosis and management of prostate cancer, which are generally considered to be the most authoritative because they are regularly updated.
See: 1. thelancet.com/journals/lanoc/article/PIIS1470-2045(14)71108-8/full text
2. https://cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/prostate-specific-antigen-psa/?region=on
These represent my position. Thank you.
Dear Dr. Hill:
If these articles accurately represent your position, that’s fine, but what these articles say is NOT what you have said before at all! For starters, the Lancet article states in the very first line that “Screening for prostate cancer with prostate-specific antigen (PSA) testing remains controversial, despite evidence that PSA testing reduces mortality.” And the Canadian article is filled with the ifs, ands, and buts that I have been trying to point out to you previously.
I never said it wasn’t controversial. I just said that screening has become a viable option for men now over 40. I stand by these articles and what I have previously said, if you don’t continue to cherry-pick where it is not needed. Learn to assess intent and gist.