Prostate Cancer - A cancer that starts in the prostate gland. The prostate is a small, walnut-sized structure that makes up part of a man's reproductive system. It wraps around the urethra, the tube that carries urine out of the body. Prostate cancer is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40.
The annual PSA debate wages on in 2012 as further data challenging the effectiveness of routine prostate cancer screening and its impact on prostate cancer deaths is published. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), the same group upon which the United States Preventative Services Task Force based their 2011 anti-PSA recommendations, maintains their claim that the Prostate-Specific Antigen (PSA) test does not reduce prostate cancer deaths.
Early this month the PLCO re-published their research in The Journal of the National Cancer Institute. The new report extended the follow-up period by six years, for a total of 13 years; however, the same conclusion was reached - widespread, routine prostate cancer screenings do not reduce prostate cancer deaths. The study is flawed by the fact that approximately 50% of the control group was actually screened with PSA at some point during the review period. "This study is really looking at the difference between routine PSA screening and intermittent screening. It is not a clean comparison of PSA testing verses non-PSA testing," reasons Dr. Samadi.
Studies out of Europe, which did show a reduced mortality benefit with PSA screening, had much lower levels of PSA screening in their control groups. One study out of Sweden, for example, found a 20 percent reduction in mortality after 14 years of follow-up.
As Vice Chairman, Department of Urology, and Chief of Robotics and Minimally Invasive Surgery at The Mount Sinai Medical Center, Dr. David Samadi remains a steadfast proponent of the annual PSA test and the life-saving opportunities it provides for early prostate cancer treatment. "Despite the increased length of the PLCO study, I don't believe it accurately reflects the progress we have made in our fight against prostate cancer," he said.
Dr. Samadi added, "The PSA test is effective and necessary in diagnosing prostate cancer. It might not be a perfect test but it's our only test, and there is evidence showing that it can reduce prostate cancer mortality. But the reality is that there's no straight line between detection and cure. Detection of a disease does not prevent its malicious impact on the body. Treatment is everything."
The PLCO study only focused on morbidity in relation to prostate cancer screening and diagnosis; it did not address the courses of treatment elected by those patients who received a positive diagnosis. Dr. Samadi clarified, "Diagnosis affords the opportunity for treatment. Prostate cancer can be a slow disease, but in its aggressive form it can spread very quickly without warning. PSA testing allows us to diagnose prostate cancer more readily in its initial stages; this is when a cure is possible with proper treatment."
A large part of the controversy over the PSA test stems from the fact that some prostate cancer tumors develop at such a slow rate that men are more likely to die of alternate medical issues or age. However, other forms of prostate cancer tumors develop very rapidly without symptoms or indication of spread. Currently, testing limitations prevent experts from establishing tumor aggression at the point of diagnosis, leaving many men with the difficult decision of how and when to treat their prostate cancer.
That reality, coupled with the potential negative side effects of prostate cancer treatment, fuels concerns about over-testing and over-treatment of the disease. Urinary control issues and erectile dysfunction are potential and difficult issues men must consider. "Not all positive diagnoses need immediate, aggressive treatment. But for those who opt for definitive treatment, it's the expertise of a specialist, particularly in the case of robotic prostatectomy surgery, that can have significant impact on the success of the treatment and a man's quality of life after recovery," Dr. Samadi said.
Dr. Samadi spoke out in 2011 about the dangers of the government task force's blanket recommendation against the PSA, the only prostate cancer screening tool available. "The risk that insurance companies could heed this shortsighted recommendation and cease benefits related to cancer prevention is unconscionable," he cautioned.
The PLCO data did give some indication that younger, healthier men could benefit from annual PSA screening, or at least a baseline screen at a younger age. Researchers also acknowledge men who are considered high risk, those with a family history or of African American descent, should consider early and regular testing.
"We can't lose sight of the lives that are saved through early detection and early treatment," reminded Dr. Samadi, "Without the PSA, a great number of men would be diagnosed with aggressive prostate cancer beyond the reach of effective treatment. That's a study we don't want to see."