Changes in prostate testing
By Jimmy Magahern
Rarely does it pay to procrastinate — especially when it comes to taking care of your health. But for men over 50 who are still putting off getting that dreaded prostate cancer screening done, relax: doing nothing just might be the best choice after all.
That, in a nutshell, is the finding published last year by the U.S. Preventive Services Task Force, which firmly came out against routine prostate-specific antigen (PSA) screening for prostate cancer. The hotly debated reversal on the decades-old practice of routinely recommending PSA tests to every male over 50 concluded that, for the majority of those tested, the tests might actually do more harm than good, leading to unnecessary surgery, radiation and hormone therapy that creates more harmful side effects than benefits.
“If you’ve been putting it off, you’re probably one of the smart people,” says Farshid Dayyani, MD, PhD, medical oncologist at Banner MD Anderson Cancer Center in Gilbert.
Task force findings
For every thousand men screened, the task force found, only one manages to beat the inevitable, and avoid cancer. Meanwhile, up to one-third will end up with urinary incontinence, bowel problems or impotence from the treatments elected to fight cancers that, odd as it sounds, the patient often could have lived with anyway.
“The PSA is a good test of the prostate gland,” Dayyani explains. “But it’s a bad test for cancer, in that it’s not specific to cancer. A prostate infection will increase your PSA level; a prostate biopsy will increase your PSA level. So you have a lot of false-positives. People who get the biopsy but then turn out not to have cancer.”
Even when the screening is right, and it correctly detects the development of prostate cancer, Dayyani says, what it’s catching is more often than not a slow-moving villain that seldom ends up being the body’s killer. “People end up carrying out a diagnosis of, quote-unquote, ‘cancer’ on conditions that nine out of 10 of them wouldn’t have died from anyway, even if no one had diagnosed it.”
Specialists have yet to come up with a better test for detecting prostate cancer early, and PSA’s, according to the April 2013 recommendations of the American Urological Association, can still benefit men between the ages of 55 to 69, African-American men and those with a family history of prostate cancer. Dayyani stresses the importance of ongoing research to identify with novel screening methods those patients who are actually at risk of dying from their prostate cancer, as for them, early detection and treatment is the only recourse.
“Ultimately, there should be a thorough discussion between men and their health care provider regarding risks and benefits,” he says, “as well as the patient’s values, prior to deciding for or against screening.”
But Dayyani says the more exciting work in his field involves helping those who do develop prostate cancer live longer, and better.
Physical castration (orchiectomy, for those who cringe at the very word), is seldom prescribed anymore, at least in the U.S., to stem the testosterone that cancer cells like to grow in. “For psychological reasons, in this country, we do chemical castration,” says the Munich-trained specialist, who transferred to the East Valley in 2011 following a fellowship at The University of Texas MD Anderson Cancer Center in Houston. “Which means we’re giving hormone shots to shut down the testosterone production in the testicles.”
New drugs prove effective
Even that procedure, temporary in that the cancer cells eventually find their own pathways without the testosterone, is being replaced by promising new drugs.
“This is where the field has been moving fastest,” Dayyani says. Relatively young chemo drugs like Docetaxel and Jevtana have proven effective, he notes. But the new hormonal drugs, like Zytiga and Xtandi, are “much better tolerated than the chemotherapy drugs, because they don’t have the side effects.” Dayyani also remains partial to Provenge, the first cancer vaccine to receive FDA approval.
“In trials, the tumor did not shrink, but the disease course slowed down, and patients in the Provenge group lived 25 months longer.”
For Dayyani, stretching the prostate cancer patient’s lifespan on what he calls “the right end of the spectrum” is more important than the patient discovering the cancer’s onset on the left end of the age chart.
“The screening conundrum is at the very, very early stage of the disease, among patients who don’t even have any symptoms,” he says. “But the exciting, novel treatments are on the other side of the spectrum, with patients who no longer respond to primary treatments. This is where we’ve made the biggest advances in the past decade.”