In May of this year, the US Preventive Services Task Force, a governmental advisory panel, came out with a recommendation against PSA-based screening for prostate cancer, the second most common cancer of men.
The Task Force concluded that PSA-based screenings cause more harm to the patient than good. As expected, the recommendation has been engulfed in controversy. Most physicians, including my colleagues in the subspecialties of urology and radiation oncology, disagree with its findings
With the incidence of death from prostate cancer still high, and because of its ability to negatively affect a man’s quality of life, we cannot stand behind such a broad recommendation – to stop PSA screening altogether for healthy men. More than 240,000 men were diagnosed in the United States last year with prostate cancer; about 30,000 of them died from the disease. Screenings are an important preventive health measure, and when we catch prostate cancer early, the cure rates are higher and more treatment options are available. An alternate for PSA-based screening for healthy men would be the digital rectal exam alone, but by the time something is detected on such an exam, the cancer is much more advanced
Prostate cancer often has no signs or symptoms. Urinary symptoms, such as frequency and a decreased stream, are also symptoms of benign prostatic hyperplasia (an enlarged prostate), and it’s often hard to tell the difference. If prostate cancer is not caught, however, it will spread, and it typically spreads to the bones. Often the first symptom is severe bone pain. This is one of the ways men die from prostate cancer -- the cancer replaces the marrow in the bones.
Understandably, like the recently issued new guidelines regarding age and frequency for women getting mammograms, this recommendation will cause men at the least to be confused, and at the worst discouraged from getting the screening. Already in my practice, I am seeing men whose primary care physicians are no longer recommending PSA screening.
It’s true that PSA tests sometimes indicate that cancer is present when it is not – what’s called a false-positive -- which could lead to more tests. The panel calls this “overdiagnosis.” We also know that once diagnosed, not all prostate cancers need to be treated, what the panel calls “overtreatment.”
However, we do know that there is a sub-group of cancer that if not caught early and left untreated, has the power to negatively affect a man’s quality of life and be the difference in how long he lives. In fact, could be the cause of his death.
Treating prostate cancer is a collaborate effort between the urologist and radiation oncologist. Because not everyone is a candidate for all types of therapy, in our consultations, we help the patient narrow down his options and guide him to make the best choice for his situation. A major factor in treatment options is whether the patient is low, intermediate or high risk which is determined by his age, life expectancy, and the stage and aggressiveness of the disease. We also discuss cure rates, which can vary depending on the treatment, and side effects such as those expected after surgery or radiation -- fatigue, bowel and urinary issues – and long term side effects, mainly impotence and incontinence.
Treatment options for prostate cancer are numerous and include surgery, radiation therapy, more experimental therapies like cryotherapy (freezing the prostate), drug therapy, and for many men monitoring and observation.
In surgery, today the procedure is done mainly through robotic prostatectomy. With radiation therapy, we have several options: brachytherapy—implanting radioactive seeds into and around the prostate; IMRT -- an eight week treatment using external radiation; and Cyberknife therapy – in which the radiation is delivered by the Cyberknife robot in four to five treatments.
We have many men in our practice, actually about 40%, for whom after initial consultation we recommend observation and monitoring of their cancers, either because their disease is not aggressive or because they are older and life expectancy is typically than 10 years. We monitor these patients every three to four months through a PSA check; and do a biopsy on an annual basis to see if the tumor is changing or how quickly it is growing. These are office procedures done by an urologist.
Another treatment option is anti-testosterone/hormonal therapy which can be used alone or in combination with other treatments. Hormone therapy can keep prostate cancer in check for about two to three years, but then it stops being effective.
On the frontier is genomic medicine in which someday soon we will be able to look at the genetic makeup of a particular cancer to help us determine whether it should be treated or monitored
All this is evidence for why I believe PSA screening should be part of a comprehensive approach to reducing prostate cancer deaths, especially for at-risk populations. Expressing its concern about the Task Force’s blanket recommendation against PSA testing, the American Urological Association says, “Men who are in good health and have more than a 10- to 15-year life expectancy should have the choice to be tested and not discouraged from doing so.”
Robert Sinha, MD
Dr. Sinha is a board certified radiation oncologist and medical director of the Center for Advanced Radiosurgery and Cyberknife Radiotherapy at El Camino Hospital in Mountain View. He earned his medical degree at Robert Wood Johnson Rutgers Medical School, completed his internship at Saint Barnabas Medical Center in New Jersey and his residency at the University of Pennsylvania. Dr. Sinha is trained in advanced cancer treatment technologies including IMR/GRT, Rapid Arc, Cyberknife and Novalis Radiosurgery to treat tumors of the central nervous system, lung, head and neck as well as prostate cancer, GI tumors, lymphoma, and gynecologic tumors. He also treats patients with breast cancer using breast brachytherapy, an alternative to traditional breast cancer radiation treatments.
PSA Test Helped Catch His Prostate Cancer in Time
After two consecutive annual tests came back with higher than normal PSA results, Fremont resident Nazir Alimohammad, 54, and his physician at Washington Hospital became concerned. They were right to be so. A biopsy came back positive for prostate cancer which had progressed to the intermediate stage. The doctor talked about surgery as an option, but Nazir was reluctant – he wanted to learn more about other options he might have. A chance meeting with a colleague led him to make an appointment with Dr. Bob Sinha at the Center for Advanced Radiotherapy and Cyberknife Radiosurgery at El Camino Hospital in Mountain View. After discussing all the treatment options with Dr. Sinha, and after many discussions with his wife, daughter and son, Nazir went ahead with brachytherapy, in which radioactive seeds are implanted in and around the prostate, followed by a course of external radiation.
“I was amazed at all the information Dr. Sinha shared with me,” says Nazir. “He took the time to go over everything, outlining all the options on a whiteboard in his office, giving the pros and cons of each. His command of both medicine and the technology made me feel very confident that I had made the right choice for me.”
Some of his South Asian colleagues and friends tried to persuade him to try the Ayurvedic approach as an alternative to surgery or radiation. “I believe in alternative treatments for certain illnesses, but in this case, no,” Nazir says. “Not when it’s cancer.”
Today, Nazir, who has been a program manager at Citrix in Santa Clara for 5 years and in the industry for 27 years, is through with the treatments. There have been some of the expected side effects, but he feels with a little more time, they will improve.
Nazir says he too has read about the recent recommendation against PSA screening for healthy men, but as a prostate cancer survivor, has some advice of his own. “I’m sharing my story so that other men won’t make the same mistake I did – waiting longer than I should have to get checked for cancer. The excellent family support, encouragement from colleagues and friends was what kept me determined to fight my cancer with courage and strength. This type of cancer can be treated if good decisions are made by the patient in a timely manner. In my opinion, if you’re over 50, don’t hesitate to get screened for PSA.”