Prostate Cancer: Every Action Has a Reaction

Steven Eric Finkelstein, MD

For those who think that men can’t die of prostate cancer, they can spend the day with me in clinic and meet some of the bravest men on the planet who are in the fight of their lives and are unfortunately afflicted with advanced metastatic prostate cancer.

Prostate cancer is the most commonly diagnosed cancer, affecting an estimated 220,800 men. In 2015, an estimated 27,540 will die of this disease. Thus, identifying those who have aggressive, potentially fast-growing disease is of paramount importance.

In 2008, there was indeed such an action. The United States Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA) screening for men over age 75. In 2012, however, USPSTF extended the recommendation against PSA-based screening to all men.

Interestingly, there were no urologists or radiation oncologists on the USPSTF panel. The recommendations were based on the following beliefs: a) the screening process can result in pain, suffering, and a small risk for other complications; b) the screening process can result in a psychological consequence of receiving a false-positive test; and c) the screening process can result in men with prostate cancer receiving overtreatment because of the potential difficulty distinguishing prostate cancers that are life-threatening from those that are indolent. Yet, numerous expert organizations, including the American Urological Association and National Comprehensive Cancer Network, support prostate cancer screening with appropriate education.

For every action there’s an equal and opposite reaction. Fewer PSA draws imply fewer patients being diagnosed with prostate cancer, implying fewer referrals to urologists, implying fewer appropriate referrals to radiation oncologists.

In the lead article of this issue of Contemporary Radiation Oncology, “Changes in Prostate Cancer Presentation for Radiation Oncology Care in Southwest Florida, 2007-2013,” the authors demonstrate a significant decrease in the volume of prostate patients seen across all radiation oncology and urology clinics in Lee County in Florida. The estimated number of low-risk patients decreased as did the number of intermediate- risk patients.

Although it is difficult to know exactly the reason behind the decrease, what profits wisdom when there’s nothing to be done? The fact is, there is a decrease in the volume of patients with prostate cancer who are seen early in the course of their disease. This occurs in an era in which treatments for prostate cancer have gotten better and better with improved radiation therapy techniques, surgical acumen, and novel agents such as Provenge, Xofigo, Zytiga, and Xtandi, which are defining the metastatic castrate resistant landscape in which a decade ago there was little.

Additionally, diagnostic improvements via available genomic testing and advanced imaging are highlighting more personalized care. Many believe we have been using primitive tools for the screening, diagnosis, and risk grouping of all patients. The introduction of advanced genetic testing for appropriate patients first identified by simple blood tests can potentially identify the patients at real risk of dying from their disease, so that ultimately the screening can be more targeted.

I encourage all who read this to think about what this means for current decision making in our own practices.