Yesterday the US Preventive Services Task Force released information that it will recommend against routine PSA testing for prostate cancer. Predictably, there has been a firestorm of responses, mostly criticizing this finding. The most vocal critics are prostate cancer patients and advocates, including their physicians. As a physician who has cared for several thousand prostate cancer patients and a member of this community, I think it is appropriate to chime in. However, what I am about to say will not set well with many. Here is an inconvenient truth: If you live long enough, you will probably develop prostate cancer. 55% of men in their 50’s and 64% of men in their 70’s have prostate cancer when their prostates are carefully examined at autopsy. And the frequency goes up from there. These men are the silent majority – the ones who had no treatment, remained continent and potent in many cases, did not have the anxiety of knowing they had cancer, and lived a full life, dying from some other cause. In fact, prostate cancer accounts for only 4% of all deaths in men. The patients who have been diagnosed and successfully treated ALL feel that prostate cancer screening saved their lives. Most of us who treat prostate cancer or participate in screening for it would like to believe the same thing. Indeed there are some retrospective studies like the famed Tyrol, Austria study that would make us believe that prostate cancer screening is having a major effect. And yet, as I previously blogged on screening, randomized trials suggest that if we save lives at all, …1) It is only in men under 65 and 2) you have to screen and treat a very large number of men (with all those side effects), to save even one life. This controversy will not go away soon, and we all await the day when molecular testing can tell us which cancers we can safely ignore, even if we find them “by accident” on screening. Until then, I think it is perfectly reasonable to salute all of our men who have lived into their 70’s and 80’s, especially those 50% walking about who have prostate cancer and don’t know it and will never miss nor be harmed by NOT being treated or screened. They are the silent majority in this debate.
The silent majority
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7 responses to “The silent majority”
When you say “if we save lives at all”, do you mean that?
On sexual side effects, the director of prostate care at Beth Israel said men should have the chance to make their own decisions with the most information available. Isn’t providing information and education ultimately always the right answer, rather than denying it?
This issue has many facets and I am curious what you think about these two. Many thanks for your great blog.
Cannot disagree with you but it is hard to know you are the “statistic” who would have been lost to PCa or had a miserable death. When I was 56 with a PSA over 10 on initial exam, it was hard to consider active surveillance. Now at 70, knowing my pleura is covered with micromets and one lesion was removed from my lung, I cannot relax either. I am willing to take the impotence, hot flashes and all so I can enjoy playing with my grandkids, fish, ski, and travel with no limitations. I have a long bucket list that I am working on and hope to have time to complete it.
“Save lives at all” may be overstated. In the context of only 4% of men dying from cancer, if we were 100% effective, the impact would be rather small, and what I mean is that we aren’t very effective plus the competing mortality issue is such a large one that it really swamps what we do. As to giving people all the information, I couldn’t agree more. However, it simply isn’t being done correctly. I did a small investigation on what is known by men visiting a screening clinic. Virtually all think that screening saves lives. Let’s say that it does…. If so, we still must face that daunting data from the European trial that we have to screen something like 1300 men and treat 47 to save one life. I fully realize this is hard to get our minds around and that EVERY patient who is treated thinks his life has been saved and that EVERY patient who is not cured by primary treatment feels that he would have been saved if his cancer had been found earlier. This is the problem of the individual versus the population data and I try to respect both.
I’m concerned that we don’t become too negative about the future of scientific advances to successfully treat advanced prostate cancer.
Instead we should be positive and encourage future scientific advances
I think there are two areas that might eventually make this conundrum easier to deal with. First would be curative therapy for advanced disease. Then it wouldn’t matter if we didn’t find anyone until they presented (as they used to) with metastases, and all the men with local disease would generally do fine unless they had significant obstructive symptoms or similar. Second would be the combination of a rock solid gene signature that had >95% accuracy in predicting a bad actor so we would know who to treat up front and who to leave alone. I’m less convinced this will become available anytime soon due to the heterogeneity of cancer in general and prostate cancer in particular. So I agree that scientific advances in treating metastases is where I would put the most hope.
Yet, when I had a consult with you 5 years ago at age 50 with a Gleason of 6 and a PSA rising to 3.4 from the previous years 2.5 your recommendation was a RP. What would you recommend today…that I should have avoided the PSA test in the first place? Or, given the tests, watchful waiting? Or would you/do you still recommend surgery. (P.S. I went to RCOG in Atlanta for seeds and IMRT and at the 5-year mark my morbidity symptoms are very minor and my PSA is ND).
Great question – What to do about a low grade prostate cancer in a young person. Generally I still favor prostatectomy on a variety of grounds. 1) It is a very long time to be asking someone to go through biopsies every 2 years or similar for active surveillance. 2) Probably there is something “bad” about a cancer that appears/is detectable at age 50 that we don’t fully understand. 3) Any kind of radiation carries with it the risk of a secondary malignancy, and a 50 year old person has (hopefully) 35 years of risk ahead of him, even if the absolute chance/year is small. and 4) Younger people tend to tolerate surgery better than older men.
All that said, I am glad you are doing so well and hope you continue to do so !