Prostate cancer:
Screenings save lives
Regular testing to detect prostate cancer in its early stages has been relatively successful. It’s a little surprising, then, that the federal government last month issued a recommendation that men 75 and older should not get screened.
The U.S. Preventive Services Task Force, a panel of 10 primary care physicians appointed by the Public Health Service to determine appropriate preventive measures, argued that tests and subsequent treatments for prostate cancer often cause more harm than good.
In its first update of recommendations for prostate cancer in five years, the task force went even further, suggesting that the testing may not be beneficial for younger men as well.
The reaction from Dr. Anthony Victor D’Amico, chief of Genitourinary Radiation Oncology at Brigham and Women’s Hospital, was quick and emphatic: The panel should reconsider these guidelines.
“If a man has at least a 10 years’ life expectancy, which can be when he’s 78 or 58, prostate cancer screening should be recommended,” he said. “Age itself should not be used as the breakpoint of when to recommend screening for prostate cancer or not.”
Life expectancy and overall health status are better indicators, according to D’Amico. He said that age is just a number.
“If a man is 55 and has other significant illnesses, such as renal failure, his life expectancy is low,” D’Amico explained. “Likewise, if an older man has congestive heart failure and a recent heart attack, you might not worry as much about a PSA.”
The PSA is the prostate-specific antigen, a blood test used to detect prostate cancer.
But a man older than 75 with a high PSA could have a reasonable life expectancy and should not be denied screening or treatment.
“Ask the question — is this man likely to live five years?” he said. In general, men die of aggressive prostate cancers within five years of diagnosis.
D’Amico said he believes that the very men who would be ignored are the ones who would benefit from screening.
“The vast majority of men with aggressive prostate cancers are those over 70,” D’Amico explained. “As men age they are more likely to get a more aggressive cancer.”
In addition, D’Amico points out, African Americans have a higher incidence of prostate cancer regardless of age, and would be overlooked if these guidelines were followed.
D’Amico bucks the system when it comes to a screening timetable as well, and offers a schedule different from what is now advised.
He prefers a schedule similar to that for breast cancer. He recommends for all men a baseline screening at the age of 35, another at 40, and one every year thereafter to detect even minor changes.
“What we’re looking for is a change in the numbers from year to year,” D’Amico said. “That’s a better indicator of cancer.”
A half-point rise in the PSA in men under the age of 60, and one full point increase in men older than 60, indicates a potential problem that requires a urological workup, according to D’Amico.
There’s no telling how following these recommendations would have changed the life of Robbie Robinson.
He had just turned 60 years old when he was diagnosed with prostate cancer.
He didn’t see it coming. For years he tried to take care of his health by closely monitoring his diabetes and cholesterol. He also had regular screenings for prostate cancer.
As far as he knew, he didn’t have any symptoms. He admits to increased frequency of urination, but diabetes has similar symptoms.
But the telltale signs were there. His PSA increased from 2.5 to 3.7 in one year. A biopsy confirmed cancer. His Gleason score, a measurement that assesses the aggressiveness of prostate cancer, was 7. Scores range from 2 to 10: cancers with higher scores have a worse prognosis.
Fortunately for Robinson, his cancer was confined to the prostate gland and had not metastasized, or spread to other parts of the body.
“It was overwhelming,” he recalled. “You always associate cancer with death.”
Depressed, Robinson, a building service manager, would come home from work and curl up in bed for hours at a time.
His wife, Shirley, at first allowed him to work through the emotional trauma, but eventually said enough was enough.
“Let’s focus on what we have to do,” she said she told him. “We’ll work on this together.”
They did, and after gathering information and meeting with doctors, Robinson decided on radical prostatectomy — surgical removal of the prostate. He was uncomfortable with his other option of seed implantation, a form of radiation therapy.
“I wanted to cut it out and rid myself of it,” he said.
So far, so good. Robinson is back on the golf course. Most important, his prostate cancer has not spread to other parts of his body. But just in case, he said he still has regular checkups.
And that’s the key — regular checkups.
Despite an ongoing debate over screenings and at what age they should begin, no one can argue they are not effective at detecting prostate cancer.
Screenings, as well as advances in treatment, are credited with lowering death rates from prostate cancer since 1975. The five-year survival rate in blacks increased from 61 percent between 1975 and 1977 to 95 percent between 1996 and 2003.
As it is now, men run a one-in-six chance of developing prostate cancer at some point in their lives. It is the most common non-skin cancer among men in this country and the second most deadly cancer in men trailing only lung cancer.
According to the American Cancer Society, more than 186,000 new cases in the United States are expected this year and about 29,000 deaths.
Age is the biggest risk factor for prostate cancer. Only 9 percent of men diagnosed with prostate cancer are under the age of 55, while almost 63 percent of all men diagnosed are older than 64.
Race is also a factor. For unknown reasons, African American men have the highest rate of prostate cancer in the world. The National Cancer Institute, an arm of the National Institutes of Health, determined that from 2001-2005 in the U.S. the rate of new cases of prostate cancer was almost 60 percent higher for black men than for whites.
Death rates were even more drastic. Black men died of the disease at more than twice the rate of whites.
Family history has an impact as well. Having a first-degree relative — father, brother or son — with the disease doubles a man’s risk of prostate cancer; the risk increases fourfold if two first-degree family members are affected.
Prostate cancer is silent in the early stages; as it progresses, it causes urinary problems. Pain In the hips, spine and ribs can indicate the cancer has spread to the bones.
Situated in front of the rectum and beneath the bladder, the prostate is a small gland that is part of a man’s reproductive system and surrounds the urethra, a thin tube that transports urine from the bladder.
Several things can go wrong with the prostate. It can become inflamed, enlarged or cancerous.
According to D’Amico, about 80 percent of all men will experience prostate enlargement.
The growth itself is not an indicator of cancer. Men commonly experience a benign non-cancerous growth of the prostate called benign prostatic hyperplasia, or BPH. It’s not fatal.
There are two screening tests for prostate cancer. The PSA is a simple blood test. In the digital rectal exam, (DRE) a clinician inserts a lubricated, gloved finger into the rectum to feel for hard or lumpy areas in the prostate for possible signs of cancer.
The tests are not perfect. Men without prostate cancer can have an elevated PSA, and some men with normal levels of PSA have been determined to have cancer. DREs can miss some cancers as well. The two tests together are better than either test alone.
The American Cancer society recommends that both tests be offered yearly to men beginning at age 50 who have at least a 10-year life expectancy. Men of increased risk — African Americans and those with a family history — should begin the screenings earlier at 45 or even 40.
Johnson is now 66 years old and credits his primary care physician at Dimock Community Health Center for recommending a prostate test. He credits his wife for providing the support he needed to get through his ordeal.
Together, they have made a healthier lifestyle a way of life. They eat more fish and salad and drink lots of water. And they both exercise regularly.
“Early detection is the key,” Johnson said. |
| Robbie Robinson won his bout with prostate cancer more than five years ago. He is still able to hit the links several times a week at the William Devine Golf Course at Franklin Park. |
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Anthony Victor D’Amico, M.D., Ph.D
Chief, Genitourinary Radiation Oncology
Brigham and Women’s Hospital
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