Controversies of Prostate Cancer

There are several controversies in prostate cancer diagnosis and treatment. The first controversy in prostate cancer is regarding early detection. In the US, most men over the age of 50 have had a prostate specific antigen test. Over 95% of male Urologists and 78% of primary care providers who are 50 years of age or older have had a PSA test themselves. US Death rates from prostate cancer has fallen 50% over the years since 1990, 5 years after the introduction of PSA testing.

Advantages of PSA

Actual and projected death rates Prostate Cancer, 1975 to 2020, CDC Data

Death rates peaked in 1990 when PSA use peaked and since then 50% decrease in death rates due to widespread use of PSA

The answers to the PSA controversy seems to be resolved at least in the minds of Urologists and primary care physicians. However practice guidelines still suggest that PSA screening is not effective.

 

This is based largely on the risks of over-diagnosis and over-treatment that result in significant side effects. In one large US study, called the PLCO Trial, authors reported no benefits from combined screening with PSA testing and rectal examination in a follow up of 11 years. Recently, the PLCO Trial has been invalidated

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JE Shoag, S Mittal, New York Presbyterian, Jim HU Weill Cornell University

  • “90% of controls in the PLCO trial had at least 1 PSA test before or during the trial.”

  • “Men in control group had more testing than intervention arm.”

  • “The contamination in the PLCO trial makes it unreliable to determine role of PSA on prostate cancer death rate.”

 

In a European study of screening for prostate cancer, the authors reported that PSA screening with rectal exam resulted in 21% reduction in death rate of prostate cancer in a follow up of 13 years. 

PSA Reduces Death Rate

  • As of now, there is only 1 randomized trial of screening PSA vs. no PSA - The ERSPC trial

  • 182,388 men - 900 cancer deaths

  • 13 years of follow up

  • PSA testing every 2-4 years vs. standard of care with no PSA

  • Men aged 55-69 years at start of trial

  • PSA screening arm shows 21% reduction in prostate cancer death at 13 years

  • 27 men need diagnoses to prevent 1 death

Schröder et al.  N Engl J Med 2009; 360:1320-1328, March 26, 2009

Schröder et al.  Lancet Volume 384, No. 9959, p2027–2035, 6 December 2014

Despite these studies, there is still some controversy in the minds of some physicians on the use of PSA in Prostate Cancer

The other question for physicians and patients is whether once PSA is elevated, who should get a biopsy. The only way to diagnose prostate cancer is by a biopsy. There are some side effects of biopsy, mostly related to infection. While side effects of infection have diminished significantly when modern protocols of antibiotic use are followed, the large number of biopsies and repeated biopsies in patients who choose active surveillance still causes some morbidity. For further discussion on the types of biopsy and advantages of each, go to our other website prostatecancerfacts.net and click on the section titled Biopsy or No Biopsy!  

Once cancer is diagnosed, there is another controversy as to who should get treatment.  Currently, it is believed that patients who have small cancers under 1cm in size and have Gleason score 6 (Gleason score is a grading of prostate cancer and 6 is considered low grade) should be on active surveillance. The term active surveillance, according to American Urology Association guidelines, implies that patients should be followed carefully with serial PSA and undergo prostate biopsies every 1 to 2 years. Many patients are unwilling to undergo biopsies this frequently and also there is anxiety associated with this follow up. 

HIFU treatment in many of these patients may provide a reasonable alternative to current treatments such as radiation and surgery. Radiation is known to cause long term side effects in a small number of patients and also is a cause of secondary cancers in some. There is also the treatment protocol itself which involves 6 to 8 weeks of treatment and more recent data suggests that very high doses of radiation over 75 G is required for effectiveness. Unless these high doses of radiation are given in a center that does hundreds of these procedures, scatter radiation on the bladder and rectum may cause significant side effects. Surgery with robotic procedures has decreased the incidence of wound related complications and hospital stays but many other complications such as cardiac events, blood transfusion, respiratory events, incontinence, erectile dysfunction, and others contribute to a morbidity over 20%.