• Prostate cancer testing and treatment research update

    As I wrote last week, there’s been a lot of prostate cancer research news lately. As Aaron wrote this morning, putting research like this in front of physicians may not be enough to change what they do. This particular batch of research on prostate cancer is not so easy to interpret. But there is lots more, which I’ve blogged about. Nevertheless, here’s the latest, followed by questions for readers. (This is kind of a raw dump.)

    Pieter Droppert on an otherwise unpublished presentation at the 2011 meeting of the American Urological Association:

    What makes the PIVOT study so important is that it is the first randomized trial in the United States to look at RP [radical prostatectomy] versus “watchful waiting.”  In all, 13,022 men were screened at 52 US centers, from which 5023 men were deemed eligible.  Surprisingly, 4292 declined randomization and 731 men were enrolled in the trial.

    [L]ooking at the groups as a whole there was no benefit of RP on survival.  […]

    Only in the high-risk groups (PSA>10) was there a significant benefit to RP, in terms of lowering Prostate Cancer Mortality. […]

    [The presenter’s] conclusion from the data was that compared to observation, RP produced “reductions in all-cause and prostate cancer mortality that were not significant and less than 3% in absolute terms over 12 years.”

    From Richard Knox of NPR on a NEJM-published paper and editorial:

    The study found 38 percent fewer prostate cancer deaths among men randomly assigned to the surgery group versus those in what the Swedes called the watchful-waiting group. Men who had surgery had 41 percent lower risk of their cancer spreading throughout the body, and 66 percent less risk of growth within the prostate.

    The survival benefits were restricted to men under 65. For this group, surgery saved one life for every seven men who had prostatectomies — considered a favorable ratio. And it applied to men with tumors considered low-risk, meaning they have a relatively low Gleason score, a marker of tumor aggressiveness. […]

    So is this a slam-dunk for radical prostatectomy? Game over?

    Far from it. In an editorial accompanying the study, Dr. Dr. Matthew Smith of Massachusetts General Hospital makes some important points.

    First, only about 1 in 20 men in the Swedish study had a prostate cancer diagnosis based on a high PSA level. Almost 90 percent had tumors their doctors could feel on digital rectal exams. But in the U.S., most prostate cancers are identified by PSA screening, and less than half have palpable tumors.

    This is important, because experts believe many prostate tumors found by PSA are likely to be slow-growing — perhaps so slow they will never cause a problem before the man dies of something else.

    The paper is here and the editorial here.

    Next, Robert Langreth of Bloomberg News reported on a Sloan-Kettering prostate cancer screening study:

    Prostate cancer screening beginning from ages 44 to 50 may rule out the risk of death from the disease in half of men, according to a study that showed some may need as few as three screening tests in a lifetime.

    The research, which analyzed blood samples donated in the 1970s by 12,090 Swedish men, showed that 44 percent of prostate cancer deaths in the ensuing years occurred in 10 percent of men with the highest levels of PSA, a protein associated with prostate cancer at high levels. The study may help reduce unnecessary tests and treatment, said the researchers at Memorial Sloan-Kettering Cancer Center.

    Screening for prostate cancer has been the subject of controversy for years as the disease is slow growing in most men. In 2009, a European study of 182,000 men found that 48 men were diagnosed and treated for each prostate cancer death prevented. Prostate cancer treatment can cause impotence, incontinence, and other side effects.

    More on the Sloan-Kettering study here.

    Finally, you likely heard about the coffee-prostate cancer study. Richard Knox summed up the findings:

    The new study shows that getting a 60 percent reduction in risk of aggressive prostate cancer requires a lot of coffee — at least six cups a day. However, men who drank three cups a day had a 30 percent lower chance of getting a lethal prostate cancer, and that’s not bad.

    The coffee need not be caffeinated. The paper is here.

    Not enough prostate cancer research results for you. See the tag.

    Questions for my physician readers or anyone else who has looked deeply at prostate cancer research: (1) Would you get a PSA test? If so, at what age? (2) If you get the test, and all appropriate follow-ups (digital exam, biopsy, and the like), what would you do if your urologist recommended treatment? Which treatment, if any, would you accept? Why?

    • By email a physician writes me:

      Re: your question, a few thoughts about prostate cancer, which I find the second-most frustratingly uncertain clinical issue I deal with (a very distant second to pain control):

      1. There have been 2 large RCTs about the effect of PSA screening on mortality. The European study (NEJM 360 (2009) (1320 – 1328)) had significant survival effect, the American PLCO (same issue 1310 -1319) had a null result with a really large problem of crossover.

      2. The study you cited of RP vs WW had a significant survival benefit.

      3. Watchful Waiting is a more active process than we act like it is – we’re not talking about expensive surgery vs cheap and noninvasive comfort.

      4. Overall prostate cancer mortality, which is still a leading cause of death in the US, is plummeting, and falling much faster in the US than in Europe where these advances are happening slower (Lancet Oncology, Volume 9, Issue 5, Pages 445 – 452, May 2008).

      5. BPH (a non-cancerous prostate condition) is wildly common. It scares patients quite a bit and makes them think of prostate cancer.

      The anti-testing crowd is recommending against a diagnostic test that has a large RCT showing a survival benefit because it leads to a treatment that has a large RCT that shows a survival benefit!

      Don’t get me wrong, I’m very, very aware of the other side to this story – these benefits are quite small, focused in high-risk patients, and there are substantial side effects. Further, the growth of _untested_ overly-expensive treatment modalities (proton beam therapy and DaVinci robots) is really extreme in prostate cancer.

      Me – I get it when the patient expresses concern about their prostate, which is very common. Ultimately once a biopsy is positive a primary care doc has very limited input – I couldn’t convince someone to try WW if I tried.

      I write this in the spirit of saying that in daily practice these are very difficult situations.

    • I am waiting until age 60 for a PSA. I have been getting digital exams. IF positive and high, I would have a prostatectomy. Robotic because I know the people who would do it and the recovery is quick. If positive but low I would WW.


    • My cancer was found sort of by accident, by a gastroenterologist who had the common (non rocket science) sense to do an MRI. It was not found by anyone else. Not by a urologist even when presented with a rising PSA test, did he do a DRE, no. Not by a PCP. Not by anyone but my 5th or 6th gastroenterologist. Where would I be today with out a PSA test or the DRE when I finally got one by the oncologist? there are doctors who are NOT doing the tests even when evidence is piling up. In my category I would be even farther down the road to those pearly gates. THE TESTS MUST BE DONE.