By Zach Goldsmith, MD, PhD
St. Luke’s Center for Urology
Prostate cancer is not only the most common cancer in men, but also the second leading cause of cancer death. Some men develop low-risk cancers with little mortality risk, while others harbor more aggressive disease. As such, it can be difficult for medical providers to put their fingers on the pulse of prostate cancer.
In 2012, the US Preventative Services Task Force (USPTF) issued a “Grade D,” recommending against routine prostate cancer screening with the Prostate Specific Antigen (PSA). This is in contrast to the recommendations of the American College of Physicians (ACP), the American Cancer Society (ACS), and the American Urologic Association (AUA).
So what are the implications for the 217,000 men diagnosed with prostate cancer each year using the current screening approach? How do we screen appropriately for prostate cancer? Can we risk-stratify newly diagnosed patients into those who require aggressive treatment from those who can be initially observed?
PSA is a biomarker that is elevated in patients with prostate cancer, even at early stages.
As tumors confined to the prostate do not cause symptoms, an elevated screening PSA test or an abnormal digital rectal examination leads to the diagnosis in the majority of men. Prior to its discovery and clinical application in the 1980s, prostate cancers were typically diagnosed when patients developed symptoms of advanced disease, including ureteral obstruction and spinal metastases.
There are conflicting results from two large randomized control trials which examined the effect of PSA as a screening intervention.
In the US Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer screening trial, which randomized approximately 80,000 men to screening with PSA and a digital rectal exam versus no screening, the risk of dying from prostate cancer was equivalent in each arm. Conversely, the larger European Randomized Study of Screening for Prostate Cancer (ERSPC) trial (150,000 men) demonstrated a significant 20% reduction in death from prostate cancer with screening over 10 years of follow-up. Of note, the larger ERSPC trial applied a more vigorous screening protocol, while the negative PLCO trial had a higher rate of PSA contamination (50% of subjects randomized to the control arm had actually undergone PSA screening during or before entering the trial).
What is the potential harm in screening?
In one word: overtreatment. With broad application of screening, many men have been diagnosed with low, or very low risk disease. As such, treatment with curative intent in the form of a prostatectomy or radiation therapy, subjects a proportion of men with low-risk disease to risks of the therapy without much potential benefit. Conversely, those patients with higher-risk disease are more likely to benefit from treatment. This was recently demonstrated in the randomized trial PIVOT, in which the strongest mortality reduction was seen in younger men with higher-risk disease who were randomized to a radical prostatectomy versus no treatment.
So is the answer to stop screening?
The ongoing concern with the USPTF guideline is that men who would clearly benefit from diagnosing their prostate cancers will not be given the opportunity to engage in screening. Most in our field predict that this will result over time in a return to the “bad old days” in which prostate cancers are diagnosed only when they become symptomatic with metastatic disease. The core group of men – younger patients who harbor aggressive disease – will certainly die prematurely without the opportunity to screen.
Rather than omitting screening, it is important to note that we now have an improved ability to manage lower risk cancers more conservatively with active surveillance.
Active surveillance is offered to select patients with specific low risk disease features validated by the NCCN: biopsy results indicating a low risk histopathology in a small volume of the prostate gland, a normal digital rectal examination, and a PSA level of less than 10. Such malignancies can certainly not be ignored, but they can be safely monitored for progression, hence the term active surveillance. Should the cancer progress with a rising PSA or a more aggressive pathology on repeat biopsy, then treatment with a curative intent can still be pursued. For those men diagnosed with intermediate or high risk disease, radical prostatectomy or radiation therapy remains the standard of care. Some men even benefit from multimodal therapy – combined surgery followed by adjuvant radiation therapy.
At the St. Luke’s Center for Urology, we support the Guidelines of the American Urologic Association: PSA screening should be offered to men between the ages of 55 and 69 years of age following an informed discussion on the benefits and risks of screening. Men with risk factors for developing prostate cancers (African Americans, or patients with a family history) should be screened starting at age 40. Men older than 70, or with less than 10 year life expectancy, should not undergo screening.
When we evaluate patients referred for an elevated PSA, we interpret the kinetics of their PSA values over time, in addition to assessing their medical co-morbidities. We counsel patients on the spectrum of aggressiveness of prostate cancer. When we diagnose prostate cancers, all management options are presented to our patients. All members of our team are highly trained in performing radical prostatectomy, including using minimally-invasive robotic approaches. We discuss active surveillance for men who are appropriate candidates. We work closely in a multi-disciplinary manner with radiation oncology, as well as medical oncology. In addition, following our patients longitudinally gives us the opportunity to actively manage cancer survivorship issues which may occur following, including urinary incontinence and erectile dysfunction.
Moreover we recognize that the conversation on the benefits and potential risks of screening can be tricky and time consuming for those who are not specialists in our field. As such, we are also happy to see referrals simply to counsel patients who may be interested in screening, and to screen them within our practice
What you should know about prostate cancer:
- Prostate cancer is the most common non-cutaneous malignancy in men. One in 7 men will be diagnosed with prostate cancer.
- The largest screening randomized controlled trial (RCT), and the one that screened the most aggressively, demonstrated a 20% mortality benefit over 10 years, and this benefit increased with longer follow-up time.
- African American patients, and those with a family history, are at an increased risk of developing prostate cancer, and should be screened at a younger age.
- We have effective therapies for both localized and advanced prostate cancers.
- We have the ability to safely survey lower risk cancers with active surveillance.
- Omitting prostate cancer screening is likely to cause a reverse-stage migration, with more men developing advanced disease and dying prematurely from prostate cancer
The 3rd Annual St. Luke’s Blue Ribbon 5K and Family Fun Walk was held September 27 at the St. Luke’s Anderson Campus gardens and fitness trail. The event raised more than $7,000 for prostate cancer awareness and men’s health efforts. Special thanks to event sponsors, including the Prostate Cancer Awareness Fund, Plantique, Courtyard Marriott, Keystone Consulting Engineers, Dr. Steven Blasi, Northgate Urology Associates, St. Luke’s Center for Urology, Tolmar Pharmaceuticals, Aardvark Sport Shop, Nazareth Run Inn, Sweat Like a Girl, Lehigh Valley Iron Pigs, Nike, the Lehigh Valley Zoo, Just Born Candy, Diner 248, Road ID, Texas Roadhouse, Easton Outdoor Company and Casa Italia Restaurant.
Gail Evans, associate vice president, St. Luke’s Development (left) and race organizer Jennifer Jones, dosimetrist in the St. Luke's Cancer Center, thank James Brown, President of the Prostate Cancer Awareness Fund of the Lehigh Valley (PCALV). PCALV was the lead sponsor of the Blue Ribbon run, funding race t-shirts and pre-event billboards.