Prostrate Screening Update: First, Do No Harm

On Jan 6th there was an update to the prostate cancer screening study showing that even with a longer follow up time, the screening is of extremely limited benefit. Given the nasty side effects of treatment, (outined below) the recommendation is not to screen with PSA. I've discussed this topic previously here, here, here

Prostate Cancer Screening Shows No Benefit

By TARA PARKER-POPE

Updated findings from one of the largest studies of prostate cancer screening show that the commonly used P.S.A. blood test did not save lives, although questions remain about whether younger men or those at very high risk for the disease might benefit.

Last fall, the United States Preventive Services Task Force concluded that healthy men should no longer be routinely screened for prostate cancer using the prostate-specific antigen, or P.S.A., blood test. That decision was based on findings from five well-controlled clinical trials, including a major American study called the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial, which studied P.S.A. testing in nearly 77,000 men ages 55 to 74...

Because prostate cancer can take several years to develop, the investigators continued to collect data after reporting the initial findings.

In a new paper published today in The Journal of the National Cancer Institute, the scientists report that the additional follow-up time didn’t change the overall conclusion: that regular P.S.A. testing does not save lives and can lead to aggressive treatments that leave men impotent, incontinent or both..

The findings suggest that the type of cancer typically detected by screening is so slow-growing that it often is unlikely to cause harm before the man dies of another cause...

“I think it supports the recommendation that for the average man in the United States, mass screening is probably not beneficial at all,’’ Dr. Andriole said. “It also will keep the discussion open about whether there are indeed subsets of men who do potentially stand to benefit from P.S.A. screening.”

What's old is new again. "The findings suggest that the type of cancer typically detected by screening is so slow-growing that it often is unlikely to cause harm before the man dies of another cause... This is what we were taught in medical centuries ago when I was a medical student.
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What's in a name? Time to rename "cancer?"

I was speaking to one of my Medical School classmates at my recent reunion about this very topic. (I went to Tulane Medical School and was speaking to Dr. Oliver Sartor, a specialist and expert in Prostate Cancer.) We were discussing this because his area of expertise is prostate cancer, and there have been such dramatic and controversial developments in that field discussed here and here. that part of the problem is the terminology. Some cancers are quite indolent, most prostate cancers are for example. It would help patients make treatment decisions if those more benign cancers were not described as cancer since that term is so loaded. Often once patients get that diagnosis their reaction is to "get rid of it." But in the case of prostate cancer, the cure can be worse than the disease.

‘Cancer’ or ‘Weird Cells’: Which Sounds Deadlier?
By GINA KOLATA

My friend’s mother got terrifying news after she had a mammogram. She had Stage 0 breast cancer. Cancer. That dreadful word. Of course she had to have surgery to get it out of her breast, followed by hormonal therapy.

Or did she?

Though it is impossible to say whether the treatment was necessary in this case, one thing is growing increasingly clear to many researchers: The word “cancer” is out of date, and all too often it can be unnecessarily frightening.

“Cancer” is used, these experts say, for far too many conditions that are very different in their prognoses — from “Stage 0 breast cancer,” which may be harmless if left alone, to glioblastomas, brain tumors with a dismal prognosis no matter what treatment is tried...
Now, some medical experts have recommended getting rid of the word “cancer” altogether for certain conditions that may or may not be potentially fatal...
Many medical investigators now speak in terms of the probability that a tumor is deadly. And they talk of a newly recognized risk of cancer screening — overdiagnosis. Screening can find what are actually harmless, if abnormal-looking, clusters of cells.

But since it is not known for sure whether they will develop into fatal cancers, doctors tend to treat them with the same methods that they use to treat clearly invasive cancers. Screening is finding “cancers” that did not need to be found. So maybe “cancer” is not always the right word for them.
That happened recently with Stage 0 breast cancer, also known as ductal carcinoma in situ, or D.C.I.S. It is a small accumulation of abnormal-looking cells inside the milk ducts of the breast. There’s no lump, nothing to be felt. In fact, Stage 0 was almost never detected before the advent of mammography screening.
Now, with widespread screening, this particular diagnosis accounts for about 20 percent of all breast cancers. That is, if it actually is cancer.

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First Do No Harm: Even Vitamins May Harm

I have been meaning to write about these recent studies for awhile. I will just direct you to the New York Times blog that covers it quite extensively. That Vitamin users would have higher rates of cancer is pretty counterintuitive, and may not prove to be the case. But there clearly is no good reason to take them according to the research. So, as always, eat your fruits and veggies and the money you save by not buying vitamins, you can spend on some organic produce instead. The vitamin industry is going strong, $9.6 billion in sales last year.

Two new studies add to the growing body of evidence that taking extra doses of vitamins can do more harm than good.

A study of vitamin E and selenium use among 35,000 men found that the vitamin users had a slightly higher risk of developing prostate cancer, according to a report published Tuesday in The Journal of the American Medical Association. A separate study of 38,000 women in Iowa found a higher risk of dying during a 19-year period among older women who used multivitamins and other supplements compared with women who did not, according to a new report in The Archives of Internal Medicine.

The findings are the latest in a series of disappointing research results showing that high doses of vitamins are not helpful in warding off disease.

“You go back 15 or 20 years, and there were thoughts that antioxidants of all sorts might be useful,” said Dr. Eric Klein, a Cleveland Clinic physician and national study coordinator for the prostate cancer and vitamin E study. “There really is not any compelling evidence that taking these dietary supplements above and beyond a normal dietary intake is helpful in any way, and this is evidence that it could be harmful.”

Ongoing Controversies in Prostate Cancer Diagnosis and Treatment

I covered some of the controversies over prostate cancer screening in previous posts. Prostate cancer is a condition that should get a bit more scrutiny when it comes to the risk/benefit ratio of treatment. This should apply on an individual basis and on a public health basis.
These are the links to my previous posts covering some of the issues with PSA testing.
http://ksparrowmd.blogspot.com/2009/09/psa-test-unreliable-and-unusable.html
http://ksparrowmd.blogspot.com/2009/03/prostate-screening-test-psa-may-not.html

This New York Times article reviewing a new book about prostate cancer is poignant because it is written by a journalist who has had first hand experience with prostate cancer. I'm linking to the article almost in full because it is so important.

A Rush to Operating Rooms That Alters Men’s Lives
August 30, 2010
(http://well.blogs.nytimes.com/2010/08/30/a-rush-to-operating-rooms-that-alters-mens-lives/?scp=2&sq=prostate%20cancer&st=cse)
"As I scuffed through the stations of the prostate-cancer cross these past two years, I sometimes wondered whether I wasn’t a dupe caught up in a Robin Cook medical thriller.
Sure, the biopsy (so I was told) showed that my prostate was cancerous. And after it was removed, the pathology report revealed that the cancer was unexpectedly aggressive, thrusting me from the relative comforts of Stage 1 to the deep woods of Stage 3.

But at least on the surface, the cancer itself never did any damage. It was the treatments that razed me — the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes. And a small voice kept whispering: What if this is all a lie? A dark conspiracy of the global medical-industrial complex?
And now comes “Invasion of the Prostate Snatchers,” by Ralph H. Blum and Dr. Mark Scholz, effectively confirming my whimsical paranoia.
Mr. Blum, a cultural anthropologist and writer, has lived with prostate cancer for 20 years without radical treatment, and Dr. Scholz is an oncologist who has treated the disease exclusively since 1995.
Their book, written tag-team style, is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.
About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.
Why? Because most prostate cancers are lackadaisical — the fourth-class mail of their kind. The authors say “active surveillance” is an effective initial treatment for most men.
They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. “Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”
Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48..."
" In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them."..
The author goes on to explain that he had a rare aggressive cancer that wouldn't have been detected short of surgery, so he was an anomaly. The article goes on.
"So yes, prostate cancer is a dark and mysterious country, and Mr. Blum and Dr. Scholz are good, levelheaded guides through these thickets. And in telling men to slow up and take a deep breath after they learn they have prostate cancer, they provide an invaluable service. I wish I had had this book back in 2008."
But all of this raises one last stark question: Was my life worth the 47 other prostatectomies that probably didn’t have to be performed?"

This writer in asking this last question poses a conundrum that most patients would never even
consider asking when their own life is at stake. And I commend the author for raising the trade off. These are the types of issues that should concern public health officials, urologists and patients. They certainly interest me in the spirit of "first doing no harm." Risk. Benefit. Think hard about it!