by Gary M. Kirsh, MD
Op-Ed originally published on TheHill.com, October 11, 2016
In recent weeks attuned readers have noticed significant research studies being shared about prostate cancer, which, unless addressed during patient-physician encounters, have the potential to leave men ill-informed about this common cancer. After skin cancer, prostate cancer is the second most common cancer among American men. According to the American Cancer Society there are more than 189,000 new prostate cancer cases each year; in fact, about one in seven men will be diagnosed with prostate cancer in their lifetimes.
Prostate cancer presents physicians and their patients with a quandary. On the one hand, prostate cancer is very prevalent, and most men do not die from it. On the other hand, in a subset of patients, prostate cancer is very aggressive, and it is actually the second leading cause of cancer deaths in men.
The variability in the behavior of prostate cancers is increasingly recognized by urologists, and technology is continuously evolving to allow urologists to establish customized care regimens for each patient. In some instances curative treatment such as surgery or radiation therapy is strongly advisable, while in many others watchful waiting and active monitoring is a much more appropriate approach. But, to make these decisions, patients and doctors must know if cancer is present in the first place.
The 2008 decision by the United States Preventive Services Task Force to declare the benefits of PSA testing inconclusive and the group’s subsequent 2012 guidance that discouraged the use of prostate-specific antigen (PSA)-based screening for prostate cancer is today contributing to worse patient outcomes. The shortsightedness of the USPSTF’s recommendation, which were something many urologists fought against, was validated in July 2016 when Nature magazine published a study showing rates of metastatic cancer climbed 72 percent between 2004 and 2012.
The study shows the average amount of prostate-specific antigen (PSA) in men who were diagnosed with metastatic prostate cancer in 2013 was nearly double that for men diagnosed in 2004. For this reason the USPSTF’s 2012 guidance must be updated so that doctors and patients are able to make care decisions based on what is best for each individual patient.
In mid-September, the results from the ProtecT study were published in the New England Journal of Medicine producing headlines across the country declaring that 99 percent of men with prostate cancer survive at least 10 years regardless of treatment. Lost in the reporting were several key points that skewed the study and made the results extremely less clear for all but the most well-versed clinician and researcher.
The first point about the study is that the majority of participants in the study were low risk patients (patients with slow growing, more innocuous cancer). The second notable point is that 60 percent of those participants who elected active monitoring ultimately received treatment. Finally, the study noted about a 50 percent decrease in the incidence of metastatic disease in patients that were treated as opposed to those that received no active treatment.
As even laymen understand, the development of cancer that has metastasized usually results in considerable suffering, and may well result in death of the patient beyond the 10 year time frame of the study. Accordingly, despite garnering headlines in the country’s highest profile outlets, the end result is the ProtecT study will do little to advance how we treat prostate cancer.
In truth, the study and the reporting on it only served to reinforce what many of my colleagues and I already knew: each case is different and urologists must be able to use all the tools at our disposal to determine the best course of action. Until such time as advanced tools and tests are able to identify which patients are most at risk for metastasized cancer there is no substitute for the urologist and patient working together to decide the best course of treatment.
Gary Kirsh, a urologist, is President of The Urology Group and a founder and the current President of the Large Urology Group Practice Association. He is also the President of the North Central Section of the American Urological Association and Past President of the American Association of Clinical Urologists and of the Ohio Urologic Society.