Over the last few months, there has been a lot of controversy regarding the risks and benefits of prostate cancer screening. According to a government advisory panel’s final report, doctors should no longer offer the PSA prostate cancer screening test to healthy men because they’re more likely to be harmed by the blood draw – and the chain of medical interventions that often follows -than be helped. Task force chairwoman, Virginia Moyer, a professor of pediatrics at Baylor College of Medicine in Houston, TX stated, “That’s because the PSA, which measures protein called prostate-specific antigen, often leads to unnecessary needle biopsies for men who don’t actually have cancer. Even worse, those biopsies lead many men to be treated for slow-growing cancers that never needed to be found and that are basically harmless.” Moyer hopes that physicians stop mentioning the PSA screening when seeing their patients. However, Ian Thompson, chairman of urology at the University of Texas Health Science Center at San Antonio and spokesman for the American Urological Association commented, “Unfortunately, there are no other better tests with which to replace the PSA, such as rectal exams, ultrasounds or variations on the PSA.” Thompson also stated how he supported some of the task force’s recommendations, such as its call to do away with mass prostate cancer screenings in shopping malls and parking lots, but think they are going too far in rejecting the PSA test completely. Thompson does not want to go back to the “bad old days” before screening, when doctors found prostate cancer only after it had become incurable.
A study published in the March 2012 issue of the New England Journal of Medicine confirmed the benefits of prostate cancer screening. An 11-year European analysis of 182,160 men found PSA screening to reduce deaths by 29% when compared to those men who did not undergo regular PSA screening. The authors concluded that the question is not if to screen, but how and who should be screened.
ChicagoProstateCenter supports Dr. Thompson’s statement above and fully supports annual prostate cancer screenings to men over 50 years old. Having treated over 15,000 men with prostate cancer, we have clearly seen the benefits of prostate cancer screening and treatment. Unfortunately, until we can clearly identify which cancers are indeed of ‘high risk/aggressive nature’ versus those that are ‘slow growing’, prostate screening is extremely valuable. Therefore, most prostate cancer is treated the same way, in order to make sure the potential aggressive cancers progress and go untreated. It is also important to include a digital rectal exam along with a PSA test for a more accurate assessment. If a diagnosis is made, we encourage patients to explore all of their options and to make an informed decision regarding their health. Furthermore, another benefit to obtaining annual PSA tests and rectal exams is that physicians can obtain a baseline PSA or status. This way, they can track the PSA behavior over time, which is another indication or how fast or slow a potential cancer is growing.
If diagnosed with prostate cancer, CPC believes the decision of whether or not to treat to cancer should be left up to the patient. If a patient chooses a ‘watch and wait’ approach and delay any intervention, our recommendation would be to undergo a more sophisticated prostate biopsy technique performed at ChicagoProstateCenter. This is called stereotactic transperineal prostate biopsy (STPB). This technique has many advantages, the first of which is its increased ability to identify occult or “hiding cancers”. Our research and the research of others have clearly demonstrated that the transrectal biopsy does miss a significant percentage of cancers that occur in the anterior or front portion of the prostate. Our data in over 2,200 patients suggests that as high as 40% of patients are thought not to have malignancy, but indeed do have malignancy. Our group has previously published this information in Urology and the Journal of Urology. The second advantage to having a prostate biopsy using the perineal approach is that the infection rate is essentially 0%. This is simply because the rectal wall or rectum in general is not penetrated by the biopsy needle. As we know, infection is not uncommon after transrectal prostate biopsy and unfortunately the bacteria that are currently being identified have significant resistance to commonly used antibiotics. Our initial experience using STPB was confined primarily to patients who were diagnostic dilemmas in that they had persistent elevation of PSA level, while the biopsies were negative. More and more commonly today, patients are requesting perineal biopsy as their initial biopsy technique. This is because they have learned of the mapping ability using this procedure.
Specifically, the STPB is able to accurately identify the location within the prostate from which the cancer was obtained. This has dramatic implications because one is then allowed to apply therapy to only the area of malignancy, while avoiding normal sections of the prostate gland that have been proven NOT to contain malignancy. A whole new field of oncology will soon appear, and that is the realm of focal therapy for prostate cancer. Finally, due to the comprehensive information that STPB establishes, one is able to make a decision as to whether watchful waiting is a viable option. Certainly this option is pursued by many individuals, however, with information based solely on transrectal prostate biopsy, one risks the possibility that a higher grade malignancy may also exist in the gland that was not identified. For these reasons, we think that STPB will definitely have a place in the future of prostate cancer diagnostics and therapeutics. With regard to prostate seed implants (brachytherapy), based on perineal biopsy data, there is no question that the implants today are much more sophisticated than those based on transrectal biopsies in the past.
Finally, it is important for patients to know that not all treatments for prostate cancer have the same outcomes or the same side effects. Many men worry about incontinence or impotence and other quality of life issues. Brachytherapy (seed implant) is a one time, out-patient procedure with cure rates that are equal to or better than surgery as well as traditional external beam radiation therapy (EBRT). Brachytherapy is touted as the safest and least expensive of the three main treatments for prostate cancer, which also include radical prostatectomy and (EBRT). Jay P. Ciezki, MD, from the Cleveland Clinic presented findings at the 2012 Genitourinary Cancers Symposium: He and his team looked at 16 years’ worth of claims-based data for 100,000 men with prostate cancer, and found that brachytherapy patients experienced the least toxicity requiring intervention, at 3.4%. For surgery it was nearly double that—6.7% of patients having prostatectomy had some problems with their genitourinary organs afterwards, as did 7% of men treated with external radiation.
In summary, brachytherapy can be done in any patient with prostate cancer. There’s not one patient that’s better treated with it than another. It’s really suitable for any patient who desires to avoid surgery and external radiation and to undergo a relatively easy-to-deliver treatment that’s going to have less impact, both long-term and short-term, on his lifestyle.
The Case for Brachytherapy: An Interview with Michael F. Sarosdy, MD, Renal and Urology News, Delicia Honen Yard March 14, 2012
Schroder FH, et al. Prostate cancer mortality at 11 years follow-up. New England Journal of Medicine. March 2012; 15:366:981-90.