By Gary Schwitzer
Several readers contacted me with concerns about a New York Times column, "A Watch-and-Wait Prostate Treatment."
So I asked the physician-reviewer I turn to most often for review of prostate cancer stories on HealthNewsReview.org
to analyze it. Here is a guest post by Dr. Richard Hoffman, MD, MPH.
He is a general internist, a Professor of Medicine at the University of
New Mexico School of Medicine and a staff physician at the Albuquerque
VA Medical Center. He also serves as Interim Director for Cancer
Prevention at the University of New Mexico Cancer Center. His areas of
research interest are prostate and colorectal cancer screening and
prostate cancer treatment outcomes, with expertise in clinical
epidemiology, health services research, and meta-analysis. He is a
medical editor for prostate cancer topics for the Foundation for
Informed Medical Decision Making and works with the Foundation to
develop shared decision making tools for prostate cancer screening and
treatment of localized prostate cancer. The Foundation is also the sole
financial supporter of my web work.
————————————————————————————–
This article, which notes the controversies surrounding prostate
cancer screening and treatment, also inadvertently highlights the
confusion, misinformation, and opportunism surrounding the disease.
First, the discussion of the treatment strategy (active surveillance)
is misleading – monitoring patients by checking PSA, digital rectal
examinations, and biopsies is not "unconventional" — the American
Urological Association treatment guidelines endorse this strategy for
men with low-risk cancers. What is unconventional — because there is no
convincing supporting evidence — are the various recommendations for
lifestyle and dietary changes and proprietary dietary supplements.
Second, presenting cryosurgery as an acceptable alternative approach
for men who are not candidates for surgery or "thrilled by the prospect
of radiation treatments" misses the point — the purpose of active
surveillance is to avoid the complications of any unnecessary treatment.
There is no convincing clinical evidence supporting the use of
cryosurgery, and the National Cancer Institute classifies it as "an
option under clinical investigation." While Dr. Katz decries the
expenses of radiation and robotic surgery, the article does not discuss
the costs — or complications — associated with cryosurgery. Dr. Katz
pleads for guidelines as to who should be treated — they exist and they
would advise against treating an 82-year-old man with an early-stage,
PSA 5, Gleason 7 cancer.
The article also glosses over a number of troubling issues related to
the prominent (but unnamed) New Yorker’s experiences with screening and
treatment. While autopsy series have shown that 30% of men over 50
harbor occult prostate cancers; the percentage is at least 70% for men
in their 80s. Many experts consider a PSA of 5 to be within the normal
range for a man over 70 — as men age their prostates enlarge and produce
more PSA. Regardless, PSA is not a very accurate test and the first
thing to do with a borderline elevation is to repeat the test.
Cancers that are low-risk — and not likely to ever require
treatment — are defined by a low PSA value and a low Gleason score. The
New Yorker had a low PSA value, though the Gleason score was
intermediate. However, the other important determinant in assessing
risk is the biopsy results. Usually urologists obtain at least 12
biopsies — the number of positive biopsies and the proportion of prostate
tissue that is cancerous are also indicators of tumor aggressiveness.
The article describes the biopsy as finding an early-stage cancer on one
side of the gland; however, sometimes these cancers are so
insignificant that they can be completely removed by the biopsy.
When the United States Preventive Services Task Force recommended
against screening men older than 75 in 2008, they were accused of
ageism. Indignant urologists questioned an intrusive government agency
that sought to deny their 80-year-old golfing partners the opportunity
to be screened (and treated) for prostate cancer. However, the 10-year
life expectancy seen as justification for screening is probably an
underestimate. A study of men with screen-detected cancers found no
survival benefit with undergoing surgery compared to no treatment after
12 years of follow-up — suggesting that men would need perhaps 15 or more
years of life expectancy to expect any benefit. Of course, no clinical
trials have enrolled men over 75, so the presumed benefits are merely
hypothetical.
The bottom line is that the prominent New Yorker’s story was an odd one to profile — at least in the way it was reported.
Patients do need to be educated about screening — and the potential
downstream consequences related to false positive tests, biopsy
complications, diagnosing clinically insignificant cancers, the
uncertainty about how and whether to treat prostate cancers, and
treatment complications. Studies have shown that informed patients are
less willing to undergo PSA testing or receive aggressive treatments.
So I asked the physician-reviewer I turn to most often for review of prostate cancer stories on HealthNewsReview.orgto analyze it. Here is a guest post by Dr. Richard Hoffman, MD, MPH.
He is a general internist, a Professor of Medicine at the University of
New Mexico School of Medicine and a staff physician at the Albuquerque
VA Medical Center. He also serves as Interim Director for Cancer
Prevention at the University of New Mexico Cancer Center. His areas of
research interest are prostate and colorectal cancer screening and
prostate cancer treatment outcomes, with expertise in clinical
epidemiology, health services research, and meta-analysis. He is a
medical editor for prostate cancer topics for the Foundation for
Informed Medical Decision Making and works with the Foundation to
develop shared decision making tools for prostate cancer screening and
treatment of localized prostate cancer. The Foundation is also the sole
financial supporter of my web work.
————————————————————————————–
This article, which notes the controversies surrounding prostate
cancer screening and treatment, also inadvertently highlights the
confusion, misinformation, and opportunism surrounding the disease.
First, the discussion of the treatment strategy (active surveillance)
is misleading – monitoring patients by checking PSA, digital rectal
examinations, and biopsies is not "unconventional" — the American
Urological Association treatment guidelines endorse this strategy for
men with low-risk cancers. What is unconventional — because there is no
convincing supporting evidence — are the various recommendations for
lifestyle and dietary changes and proprietary dietary supplements.
Second, presenting cryosurgery as an acceptable alternative approach
for men who are not candidates for surgery or "thrilled by the prospect
of radiation treatments" misses the point — the purpose of active
surveillance is to avoid the complications of any unnecessary treatment.
There is no convincing clinical evidence supporting the use of
cryosurgery, and the National Cancer Institute classifies it as "an
option under clinical investigation." While Dr. Katz decries the
expenses of radiation and robotic surgery, the article does not discuss
the costs — or complications — associated with cryosurgery. Dr. Katz
pleads for guidelines as to who should be treated — they exist and they
would advise against treating an 82-year-old man with an early-stage,
PSA 5, Gleason 7 cancer.
The article also glosses over a number of troubling issues related to
the prominent (but unnamed) New Yorker’s experiences with screening and
treatment. While autopsy series have shown that 30% of men over 50
harbor occult prostate cancers; the percentage is at least 70% for men
in their 80s. Many experts consider a PSA of 5 to be within the normal
range for a man over 70 — as men age their prostates enlarge and produce
more PSA. Regardless, PSA is not a very accurate test and the first
thing to do with a borderline elevation is to repeat the test.
Cancers that are low-risk — and not likely to ever require
treatment — are defined by a low PSA value and a low Gleason score. The
New Yorker had a low PSA value, though the Gleason score was
intermediate. However, the other important determinant in assessing
risk is the biopsy results. Usually urologists obtain at least 12
biopsies — the number of positive biopsies and the proportion of prostate
tissue that is cancerous are also indicators of tumor aggressiveness.
The article describes the biopsy as finding an early-stage cancer on one
side of the gland; however, sometimes these cancers are so
insignificant that they can be completely removed by the biopsy.
When the United States Preventive Services Task Force recommended
against screening men older than 75 in 2008, they were accused of
ageism. Indignant urologists questioned an intrusive government agency
that sought to deny their 80-year-old golfing partners the opportunity
to be screened (and treated) for prostate cancer. However, the 10-year
life expectancy seen as justification for screening is probably an
underestimate. A study of men with screen-detected cancers found no
survival benefit with undergoing surgery compared to no treatment after
12 years of follow-up — suggesting that men would need perhaps 15 or more
years of life expectancy to expect any benefit. Of course, no clinical
trials have enrolled men over 75, so the presumed benefits are merely
hypothetical.
The bottom line is that the prominent New Yorker’s story was an odd one to profile — at least in the way it was reported.
Patients do need to be educated about screening — and the potential
downstream consequences related to false positive tests, biopsy
complications, diagnosing clinically insignificant cancers, the
uncertainty about how and whether to treat prostate cancers, and
treatment complications. Studies have shown that informed patients are
less willing to undergo PSA testing or receive aggressive treatments.