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Prostate Cancer Testing
MEDICAL NEWS & INFORMATION
Hoey & Farina, P.C.
Personal Injury Lawyers / Wrongful Death Attorneys
(Printed With Permission)
Consumer Reports on Health
Vol. 12, No. 8
New York City Mayor Rudolph Giuliani doesn't usually waffle on the issues. But when he was diagnosed with prostate cancer this spring he reportedly spent more than a month pondering the best treatment for his condition. Surgery? Radiation? Or waiting it out?
Experts disagree on the best treatment for this malignancy that kills more men each year than any other tumor except lung cancer. They even disagree on the role of early detection. The U.S. Preventive Services Task Force, an influential government panel, recommends against routine testing for prostate cancer, arguing that treatment may be worse than the disease.
The American Cancer Society and the American Urological Association disagree. So do Consumers Union's medical consultants. But deciding whether to test for the disease is a complex issue, and choosing the right therapy is difficult. Here's what you need to know to help you sort through those often painful choices.
TO TEST OR NOT TO TEST
The prostate-cancer blood test measures the level of a protein called prostate-specific antigen (PSA), which is usually higher than normal when the prostate gland is enlarged, inflamed, or cancerous. The government task force and a number of physicians have raised two major objections to using the PSA test to screen men for prostate cancer. First, studies show that anywhere from 30 to 60 percent of men eventually develop prostate cancer. But the malignancy often grows so slowly that it smolders harmlessly within the prostate for decades. Some researchers and physicians worry that the test may detect many of those un-aggressive tumors and thus lead to an avalanche of needless surgery and radiation therapy. Second, critics have long maintained that there is no good evidence that early detection of prostate cancer actually saves lives.
But recent evidence has undercut both of those arguments and strengthened the case for PSA testing. First, several studies have carefully analyzed thousands of prostates that were surgically removed because of an elevated PSA level followed by a biopsy that confirmed the cancer. The studies show that 75 to 95 percent of those cancers posed a substantial risk of turning deadly within an estimated average of 15 years; many of them would have turned deadly within 5 to 10 years.
Second, growing evidence strongly suggests that PSA screening is saving lives, by allowing doctors to catch the aggressive cancers early. From 1991 (the latest year analyzed), the number of prostate-cancer deaths in the U.S. fell by 16 percent, the first decline in decades. That occurred despite a sharp increase in the number of prostate cancers detected during that period. An Austrian study, presented in April at the annual American Urological Association meeting, provides stronger evidence. From 1993 to 1998, the prostate-cancer death rate dropped by 42 percent in Tyrol, the only Austrian state where PSA screening is free and where most men get tested; in the rest of the country, prostate-cancer mortality had held steady.
Recommendation: Our medical consultants say the available evidence is sufficiently strong to justify annual PSA testing for all men over age 50 who can reasonably expect to live more than ten years. Younger high-risk individuals high-risks individuals - including men who are African-American, or, like Mayor Giuliani, have a father or brother who had the disease - should start getting screened at age 40.
In addition, all PSA testing should be accompanied by a digital rectal exam, in which the doctor evaluates the gland by inserting a gloved finger into the rectum. The digital exam can help detect not only rectal cancer but also some of the prostate cancers missed by the standard PSA test.
HOW TO TEST
Some of the PSA in the blood is bound to other proteins; the rest floats freely. In the standard PSA test, physicians consider only the total amount of circulating PSA. The usual minimum PSA score that warrants a biopsy is 4.0 nanograms per milliliter. If the PSA level rises 1.5 points or more during a two-year period, consider biopsy, even if the total score is below that threshold.
The standard approach not only misses some cancers but can also raise false alarms; in fact, only about 25 percent of elevated total-PSA scores are actually caused by cancer. IN other cases, the elevation is due to benign enlargement, a very common condition in older men, or to inflammation of the gland due to infection. Each of those false alarms necessitates a mildly uncomfortable, expensive biopsy - about $500 to 800, on average - to rule out cancer. (You may want to ask your doctor to apply lidocaine, a topical anesthetic, before the biopsy.)
To increase the test's accuracy, doctors have modified the analysis of PSA scores by considering either the man's age or the individuals components of the total PSA score. Here's what our medical consultants say about those changes:
Younger age, lower PSA. Studies show that lowering the threshold for under going biopsy from the usual 4.0 nanograms per milliliter to 2.5 in high-risk men under age 50 leads to only about 5 percent more biopsies, but identifies about 20 percent more cancers. In addition, using a threshold of 3.5 for men in their 50s probably has similar benefits.
Note that some physicians now employ the opposite approach: higher thresholds for men over age 60. While that strategy cuts down on the false alarms, it increases the number of missed cancers by a roughly equal amount.
Recommendation: The best strategy for improving the accuracy of the PSA test is to use lower threshold values for men in their 40s and 50s. Raising the threshold for older men is not advisable.
Free PSA. Men with prostate cancer tend to have a smaller percentage of free PSA than other men have. SO when the total PSA score is minimally elevated, some doctors now consider the ratio of free to total PSA; they recommend biopsy only when that ratio is less than 25 percent. That cuts back on the number of unnecessary biopsies by about 20 percent, while missing only about 5 percent more cancers. And some evidence suggests that the missed cancers are usually the least aggressive ones.
Recommendation: Men who are willing to tolerate a slightly increased chance of missing a cancer in order to gain a much greater chance of avoiding a needless biopsy may want to consider using the free-to-total PSA ratio, particularly when the total PSA is only slightly elevated for a man's age. But the safer, and thus generally preferable, route is to rely on the total score, not the ratio. (The free-PSA test is helpful to clarify the results when a biopsy fails to find any cancer even thought the total PSA score is elevated. I that case, it's possible that the biopsy simply missed the cancer. A low free-to-total ratio may then warrant repeating the biopsy, while a higher ratio would tend to bolster the negative result.)
Testing dos and don'ts: All men should take these steps before having their PSA measured to help ensure an accurate result:
· Don't ejaculate for two days before the test, since that can raise PSA levels.
· Have your blood drawn before, not after, the rectal exam, which may also raise the PSA level.
· Remind your doctor if you're taking finasteride (Propecia, Proscar), which can lower the total PSA level (but not the free-PSA level). Also tell your doctor if you're taking the herbal formula PC-SPES or large doses of the antioxidant lycopene, since they may also lower the PSA level. (Studies have recently shown that the herbal remedy saw palmetto, often used to treat prostate enlargement, does not affect the PSA - though you should still inform your doctor if you're taking the supplement.)
· Have your PSA measured at the same laboratory, using the same method, each year. · If the PSA reading indicates a borderline elevation or a significant increase since the previous reading, repeat the test in three or four months. If the initial reading indicates a clear-cut elevation, repeat the test immediately, to confirm that finding. You may want to ask your physician about prescribing antibiotics before repeating the test, to rule out possible prostate inflammation.
SURGERY OR RADIATION
If the biopsy confirms cancer, the first step is to determine the odds that the malignancy is confined to the gland and thus potentially curable - as it is in some 70 to 85 percent of cases. To predict whether the cancer has spread, your physician should use a formula that combines three factors: the PSA level, the results of the rectal exam, and the "Gleason score," which measures the aggressiveness of the cancer cells.
When the formula indicates that a tumor is probably still localized, surgery to remove the entire gland has a ten-year cure rate of 70 to 90 percent. (In the remaining 10 to 30 percent, either the formula was wrong or the surgeon failed to remove all of the gland.) That success rate is at least as high as any other prostate treatment's. The available evidence, while limited, does suggest that surgery is probably more effective than other treatments as preventing cancer recurrence beyond ten years.
Surgery poses certain risks, however, notably permanent urinary incontinence in an average of about 10 percent of cases and impotence in about 60 percent. But the impotence rate is often lower when a highly skilled surgeon performs a version of the operation designed to spare the nerves required for an erection, without jeopardizing chances for a cure. Even when surgery does cause lasting impotence, the condition can usually be treated successfully with sildenafil (Viagra) if enough nerves were spared. (Sildenafil also effectively treats impotence caused by radiation therapy.) Moreover, the rates of sexual and urinary complication from other prostate-cancer treatments are nearly as high as those from surgery, and the rate of fecal incontinence may be even higher.
Recommendation: Surgery provides the best chance of a permanent cure and has risks comparable to those of other therapies. It's the best option for most men whose prostate cancer appears to be confined to the gland and who can expect to live more than ten years or so if the cancer is cured.
You can increase your chance of a surgical cure and reduce your risk of complications by finding a skilled surgeon. Look for someone who:
· Is certified by the American Board of Urology.
· Performs nerve-sparing surgery.
· Performs the operation several times per week.
· Says his or her surgical complication rates are below 60 percent for impotence and 10 percent for incontinence.
However, surgery is not appropriate for some men, notably those who are sufficiently weakened by sickness or advanced age - in general, over 70 or so - that the normal, generally small risks of surgery and general anesthesia rise sharply. Illness and age can also slow recovery from surgery. The following is a rundown on the three most common alternatives:
External beam radiation. Several studies lasting up to ten years suggest that standard radiation therapy, which is designed to destroy the prostate gland, prevents recurrence about as effectively as surgery does. But since radiation doesn't eliminate the entire gland as reliably as surgery can, it's possible that the malignancy will re-emerge after a decade or more. Beam radiation treatment lasts seven weeks, five days a week, for about two to three minutes. This type of treatment causes permanent impotence and urinary incontinence about as often as surgery does, and It's more likely to cause fecal incontinence as well s temporary rectal bleeding. But again, the success rates may be higher and the complication rates lower when the beams are administered by a skilled radiation oncologist.
Recommendation: Because radiation is less traumatic than surgery and has roughly comparable ten-year success rates, it's usually the preferred treatment for men whose life expectancy is less than a decade because of other health concerns. If you decide to undergo beam radiation, look for a radiologist who:
· Is certified by the American Board of Radiology.
· Practices at a medical center that uses a precise targeting technique called three-dimensional conformal therapy, and has treated at least 20 patients with that technique.
· Says his or her complication rates are lower than the above-mentioned averages for surgery.
Brachytherapy. In this procedure radiologists implant dozens of radioactive "seeds" directly in the prostate, using hollow needles inserted into the gland through the perinuem, the area between the anus and the scrotum. A growing number of doctors and patients are now choosing brachytherapy, since it's less traumatic than surgery and requires only one day in the hospital, compared with three days for surgery and seven weeks of treatment for beam radiation. Moreover, a few studies published several years ago suggested that the procedure was almost as effective as surgery, with much lower complication rates. However, recent studies have raised doubts on both accounts.
A Harvard study found that men with moderately or highly aggressive cancers who receive the radioactive seeds are about three times as likely to have a relapse within five years as those who undergo either surgery or beam radiation. Another study, from Seattle, involving men with less-aggressive tumors, found a ten-year recurrence rate of about 40 percent after seed therapy, roughly double the rates for surgery or beam radiation.
In addition, recent reports indicate that the risks of impotence and urinary incontinence are nearly as high for the seeds as for the other two treatments. And seeds, like beam radiation, appear to pose a greater risk of fecal incontinence. Indeed, a recent study from the University of California at Los Angeles that compared the overall quality of life 18 months after surgery or seeds found no difference between the two. Because of those problems, some radiologists now combine seeds with beam radiation. But there's little evidence that the combination works any more effectively than beam radiation alone, and it's more likely to cause side effects.
Recommendation: This procedure appears to make sense only for men whose overall health or advanced age precludes both surgery and standard radiation therapy. However, those men may be served just as well by watchful waiting (see below). If you do opt to receive the seeds, look for someone who is certified by the American Board of Radiology and who has performed at least 25 procedures.
Watchful waiting. Physicians can now use the PSA level, biopsy results, and rectal examination to help predict which tumors are least likely to ever spread beyond the gland, and thus which patients might be appropriate candidates for watchful waiting, or simply monitoring the disease and trying to control it if it spreads. For example, one study that followed some 770 mean who chose to forgo treatment found that those with the least aggressive tumors faced less than a 10 percent risk of dying of cancer in the next 15 years. In comparison, men who had more aggressive tumors faced a 20 to 90 percent risk.
Recommendation. Watchful waiting is a reasonable choice mainly for men whose health or age makes it unlikely that they will live longer than five or ten years, especially when they have low PSA and Gleason scores (under 10 and 5, respectively) and the rectal examination does not detect any palpable tumor.
Treating advanced cancer:
Aggressive options when the tumor has spread:
When the combination of your PSA level, digital exam, and biopsy results suggest that the cancer has probably escaped the prostate gland, doctors will try to assess how far the malignancy has spread. That usually involved performing a bone scan and possibly a magnetic resonance imaging (MRI) or computerized tomography (CT scan of the abdomen and pelvis. (Some urologists order a bone scan even on patients who almost certainly have localized cancer, to rule out the slight chance of spread to the bones, as well as to provide a baseline image of the bones to monitor the progress of the disease.)
If those imaging tests fail to detect any spread, it's still possible that the cancer is confined to the gland. It's also possible that the disease may have spread only to an adjacent region: the capsule that surrounds the prostate, the tiny seminal-fluid-producing glands adjacent to the prostate, or the nearby lymph nodes. In those cases, cure is still possible, though much less so than when the cancer remains confined to the gland itself.
A STEPPED-UP ATTACH
The best treatment in such cases is even more controversial than for localized cancer. But CU's medical consultants say that the same general guidelines - surgery for younger men, beam radiation for older men - still usually apply. Some doctors recommend taking an especially aggressive approach to these potentially curable cancers by adding other treatments to the surgery or radiation: chemotherapy, testosterone-blocking drugs (since that male hormone fuels the growth of prostate cancer wherever it spreads), or radiation (to supplement surgery).
When the malignancy has already reached the bones or other organs, doctors focus on attaching the testosterone levels. One option is "medical castration" via periodic injections of a drug that blocks testosterone production. The alternative is actual removal of the testicles, which produce most of the hormone.
Antihormone treatment causes loss of sex drive, impotence, and other changes such as tenderness and enlargement of the breasts and even hot flashes. But it can ease cancer symptoms and may prolong life by a few months to several years.
Many men with prostate cancer augment their treatment with alternative therapies, especially herbs and megavitamins. A few small studies in men with cancer do suggest that an herbal formula called PC-SPES, a combination of several Chinese herbs, as well as high doses of the antioxidant lycopene, may lower PSA levels. That might indicate that they're fighting cancer. However, that effect is far from proven. If you do take PC-SPES, lycopene, or any other alternative treatment, tell your doctor. Those agents often have side effects. For example, PC-SPES may produce some of the same side effects as anti-testosterone therapy, as well as potentially dangerous blood clots. Moreover, since doctors monitor the effectiveness of prostate-cancer treatment in part by tracking PSA levels, they need to know about anything you take that might influence PSA levels.
Since the advent of PSA screening a decade ago, the mortality rate from prostate cancer has dropped, strongly suggesting that the early diagnosis and aggressive treatment of localized prostate cancer saves lives.
Men who can expect to live longer than a decade should generally have their PSA level measured annually, starting at age 50; high-risk individuals, African-Americans and any man whose father or brother had the disease- should start testing at age 40. Talk to your doctor about lowering the threshold for worrisome scores from traditional 4.0 to 2.5 if you're in your 40's and to 3.5 if you're in your 50's.
If it's likely or even possible that the cancer is confined to the glad, surgery is usually the treatment of choice for men who can expect to live more than ten years. Finding a skilled surgeon who performs nerve-sparing surgery can increase the chance of cure and decrease the risk of incontinence and impotence. If impotence does occur, Sildenafil (Viagra) may restore potency, particularly after the nerve-sparing operation. (Sildenafil often helps after beam radiation, too.)
External-beam radiation is usually the best choice for men who have a life expectancy of no more than a decade. Look for a radiologist who performs three-dimensional conformal therapy and has the favorable complication rates described above. Radioactive seeds are generally not a good choice, since on average they're almost as likely to cause complications and much less likely to cure the cancer. Watchful waiting is a reasonable option for men with a life expectancy under five to ten years whose PSA levels, biopsy results, and rectal exam suggest they have a particularly slow growing tumor.
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