The tale of two prostates

Allen, 56, has a decision to make. Should he start prostate cancer screening? He knows two prostate cancer survivors.

His father was diagnosed with prostate cancer, young – in his 50s. Opting out of treatment on his doctor’s advice, he died at age 84, of Alzheimer’s complications.  

His friend Kevin, 73, was diagnosed at 53. He underwent prostatectomy, radiation and followed up diligently. Though he felt fine, last year a workup showed bone metastasis to his ribs, shoulder and hip.

Prostate cancer is very common.

The lifetime chance of prostate cancer diagnosis in men is 1 in 6 (16 percent). But the actual incidence is higher. Autopsy studies show that by age 70, 70 percent of men have prostate cancer. One in 41 (2.4 percent) die from it; most, like Allen’s father, will outlive this cancer. (In U.S., the No. 1 cause of death is heart disease – 1 in 4.)

Prostate cancer screening potentially saves life – 1 per 800 men screened. But the process is anything but straightforward.

The United States Preventive Services Task Force (USPSTF), whose expert panel has seesawed like a 7-year-old in an ice cream shop, advised against prostate cancer screening in 2012; now it’s for “individualized decision,” which meshes better with other organizations. Basically, it wants you, the informed patient, to decide if screening is appropriate for you.

Let's get down to brass tacks.

Here’s the first problem: overdiagnosis. The cancer screening test measures PSA (prostate-specific antigen), a protein produced by normal and abnormal prostate. It isn’t specific to cancer.

Most mildly elevated PSA levels are caused by reasons other than cancer, like age-related enlarged prostate, or benign prostate hypertrophy, which causes men to dribble when urinating. Screening leads to unnecessary procedures and mental stress.

Second, prostate cancer exists at all PSA levels. Using the current 4 ng/mL cutoff, 15 to 25 percent of those with “normal PSA” can have cancer on biopsy.

Third, overtreatment. Prostate cancers are relatively indolent. A recent trial on prostate cancer patients showed that those receiving active treatment (prostatectomy or external radiation) and those receiving active monitoring had similar survival after 10 years of follow-up. But the treatment group had higher incidence of impotence, urinary incontinence and bowel dysfunction.

To minimize harm, USPSTF recommends screening between the age 55 and 69, and recommends against prostate cancer screening for those over age 70. Know the pros and cons of screening and your personal values.

Kevin is now on leuprolide, an anti-testosterone injection he gets every three months to keep cancer at bay. He’s getting hot flashes (a real icebreaker in any conversation), exercising, keeping his weight down, waiting for more studies next week … coping well.

In the end, the decision comes down to whether you belong to the school of “luck is not chance, it’s toil” or the school of “what you don’t know can’t hurt you.”

And Allen? He decided against prostate cancer screening – at least for today.

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Volume 10, Issue 14, Posted 10:04 AM, 07.17.2018