The diagnosis and treatment of prostate cancer remains a widely discussed and at times controversial topic.
This debate of perspectives was revived lately, when actor and filmmaker Ben Stiller published an essay revealing he survived prostate cancer. He credited the prostate-specific antigen (PSA) test at the age of 46 (well below the suggested age of 50 in the U.S.) with saving his life. His post was widely circulated, especially among men. Almost immediately, health advocates and medical writers challenged his conclusion.
The controversy stems from the fact that, for some men, prostate cancer does not need to be treated. For others, not treating it would be lethal. But treatment requires detection, and detection doesn’t happen without early screening.
“We need to recognize that detection is key to men’s health, which often means PSA testing earlier than suggested by the current guidelines. Also, it’s necessary to keep the detection discussion separate from when treatment is and isn’t necessary,” says Dr. Rajiv Singal, Director of Urology at Medcan and a urologist at Michael Garron Hospital.
“Ultimately, biopsy is the most definitive method of diagnosis. But given its invasiveness and potential for risk, we need the PSA alongside other risk factors such as family history and ethnicity, to decide whether biopsy is the right step.”
Dr. Singal’s perspective is also supported by Dr. James Aw, Chief Medical Officer at Medcan, who cites research from Memorial Sloan Kettering, Northwestern Medicine and recent data on baseline PSA testing.
“A study led by Memorial Sloan Kettering investigators indicates nearly half of all prostate cancer deaths by age 75 occur in men with high PSA levels at age 45,” says Dr. Aw. “And prostate-specific antigen levels at midlife predicted subsequent lethal prostate cancer in men who participated in the Physicians’ Health Study and underwent opportunistic screening.”
“The PSA test is by no means perfect. However, it does form an important component in an ongoing and developing series of algorithms designed to predict whether a given male will develop prostate cancer, and whether that cancer will be a dangerously aggressive form of the disease. Early detection of the aggressive forms of prostate cancer in males aged 65 or younger saves lives,” says Dr. Aw.
“Initial PSA levels can vary between individuals so a test in the early 40s can provide a baseline and allow us to better tailor clinical follow-up if changes are detected in later years,” says Dr. Singal.
“Some men are at increased risk because of ethnicity, a family history of prostate cancer, or age. Men at high risk should talk to their primary care provider even earlier than their 40s. However, in my experience, the majority of aggressive cancers have been found in men with seemingly no risk factors – underscoring the importance of baseline testing.”
This summer, researchers at Northwestern Medicine found that metastatic prostate cancer cases were increasing, especially among men ages 55 to 69, who could benefit the most from screening and early treatment.
“If I were a patient, I would want to be vigilant,” said senior study author Dr. Edward Schaeffer, chair of urology at Northwestern University Feinberg School of Medicine and Northwestern Medicine. “I firmly believe that PSA screening and rectal exams save lives.”
PSA test does not detect cancer, but measures elevated PSA levels and is key to catch cancer at an early stage. The PSA is an important marker for a disease in which symptoms are not always present. Early detection helps determine those cases where treatment would be life saving.
Over the last few years, critics have suggested the PSA test causes harm because:
Often tumours detected, whether cancerous or symptom-free, are slow to progress and do not require treatment. Additionally, the survival rate among men with prostate cancer is very high. This fact has influenced the Canadian Task Force on Preventive Health Care in 2014 to recommend against PSA testing for men who had never been diagnosed with the disease. It was said the benefits are too small and the risk of harm too great.
Because of these reasons, many Canadian men are unclear about whether the PSA test is right for them.
A few weeks before Stiller’s revelation, The Globe and Mail’s health columnist, André Picard, published a column titled Prostate cancer? Relax, and don’t rush your treatment, which covered a landmark study published in the New England Medical Journal. The study found the choice of between treating and not treating prostate cancer would appear to hinge on balancing the risks of progressive disease versus the side effects of the interventions (i.e. incontinence, impotence and depression).
In his personal essay, Stiller revealed his Gleason score of 7 was categorized ‘mid-range aggressive cancer’ and he eventually had a robotic-assisted laparoscopic radical prostatectomy.
That form of treatment may not be right for most men. But getting the PSA test to support early detection is definitely right, according to Singal.
“It gives you the choice to manage your own health. Given the monitoring and treatment options available, it is inexcusable that prostate cancer should be missed or ignored,” adds Dr. Singal. “I fully appreciate that men may be fearful of the process – but without a quick check, physicians can’t know what they are dealing with. It is critical to their health and well being that Canadian men be aware, talk to their doctors and, in my opinion, get tested early.”
Dr. Aw has regular columns with the National Post and the Huffington Post. Dr. Singal is an assistant professor of surgery at University of Toronto, and he blogs regularly on health issues on his website.
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