Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Tuesday, October 28, 2014

Prostate Cancer Screening

"[Recommendations against blanket screening] may do a disservice to Canadian men who are at risk for prostate cancer."
"The Canadian Urological Association feels that it should be individualized, in discussion with the patient."
"Prostate cancer deaths have dropped by 45% since we started screening back in the '80s. There are patients who would benefit from screening."
Dr. Anil Kapoor, professor of urology, McMaster University

"If … PSA testing stops, then what I think is predictable is we’ll go back to the era of 30 years ago when most patients presented with advanced disease. The mortality will go back up and in 15 or 20 years the task force will reconvene and say, 'Oh, you know something? We blew it'."
"There’s been a complete revolution in this field over, I would say, the last five to eight years, towards what’s called active surveillance. Patients with the low-grade cancer, which is about half of newly diagnosed cancers, are simply not treated nowadays."
Dr.Laurence Klotz, urologist, Sunnybrook Health Sciences Centre, Toronto

"We continue to believe that a thoughtful discussion between patient and provider is the better way to approach PSA screening and that a widespread recommendation [against PSA testing] would particularly put our at-risk men in a vulnerable position."
Dr.Tony Finelli, uro-oncologist, Princess Margaret Cancer Centre, Toronto
A surgeon performs a robot-assisted prostate tumorectomy. Prostate cancer is the most commonly diagnosed non-skin cancer in men and is usually not life-threatening.
A surgeon performs a robot-assisted prostate tumorectomy. Prostate cancer is the most commonly diagnosed non-skin cancer in men and is usually not life-threatening. (Jeff Pachoud/AFP/Getty)

The Canadian Task Force on Preventive Health Care has issued new guidelines for Canadian doctors in using a blood test that at one time was looked upon as a failsafe guide in early cancer detection. The Task Force feels that PSA screening has proven over time to produce fewer than one percent reductions in death linked to prostate cancer.

Their feeling as health protocol authorities is that based on the evidence they see before them through scrutiny of research into the subject, that the harms that have become evident in the wholesale use of PSA screening for men over 50, the recommended age group which PSA testing targets, outweigh the presumed benefits.

Most cancers detected by PSA screening, the expert panel points out, tend to be slow-developing, and non-life-threatening. They state that as many as 56% of all men diagnosed in Canada with prostate cancer fall into the category of being over-diagnosed. In the sense that the cancer would never have caused symptoms, much less threatened the individual's life during the natural span he was given to live.
Key recommendations:
  • For men under age 55 and over age 70, the task force recommends not using the PSA test to screen for prostate cancer. This strong recommendation is based on the lack of clear evidence that screening with the PSA test reduces mortality and on the evidence of increased risk of harm.
  • For men aged 55–69 years, the task force also recommends not screening, although it recognizes that some men may place high value on the small potential reduction in the risk of death and suggests that physicians should discuss the benefits and harms with these patients.
  • These recommendations apply to men considered high risk—black men and those with a family history of prostate cancer—because the evidence does not indicate that the benefits and harms of screening are different for this group.
Men are exposed to needless treatments as a result of over-diagnosis, fear rushing them into treatments they don't really need, to treat a condition that though not necessarily benign, will present with no threatening crises during their lifetimes. That treatment can lead to other conditions far more deleterious to an individual's quality of life, consequentially.

Conditions such as impotence, incontinence and complications of other varieties resulting from radiation, surgery, and hormone therapy.

The new guidelines advanced by the Task Force on Preventive Health Care in Canada was published in the Canadian Medical Association Journal. It took mere hours after the publication of the guideline for critics to warn that following the new recommendations would result in increased cases of advanced prostate cancer.

Prostate Cancer Canada stated that in their opinion early detection "can be the difference between life and death." Dr. Anil Kapoor, head of the genito-urinary oncology program at the Juravinsi Cancer Centre and St. Joseph's Hospital in Hamilton protested that the task force had chosen to ignore other studies that favour a survival advantage with PSA screening.

The prostate specific antigen test (PSA) works by measuring a protein produced by the prostate gland. Through the administering of the test, the higher the man's blood PSA levels are, the likelier he is, according to prevailing medical opinion, to have cancer. On the other than, higher-than-normal PSA counts needn't necessarily affirm that prostate cancer is present. Indeed, even with low PSA levels appearing, cancer may be present.

A perfect detection tool it most definitely is not. There are physical symptoms, on the other hand, that should certainly not be overlooked, and they include weak urinary flow, an urgent need to urinate, frequent urination throughout the day and particularly at night-time, and blood in the urine. With the exception of the very last symptom, all the others preceding it are also indicative of a more common benign but problematical enlarged prostate condition.

Dr. Neil Bell, chair of the task force's working group on prostate cancer screening, a professor in the department of family medicine at the University of Alberta, explained that prior to the PSA test, "We didn't really have anything, except for the digital rectal examination." On the other hand, the test was widely acclaimed and adopted before evidence surfaced that it represented a reliable screening tool.

Because most prostate cancers enjoy a hopeful prognosis, the survival rate now is the highest among all cancers in men. About 95 percent of men diagnosed with prostate cancer survive at least ten years. The PSA test was introduced twenty years ago. The number of new cases and incidence of prostate cancer have grown since then, and over-diagnosis is recognized as the culprit.

The task force supports its conclusion leading to recommending less use of the PSA test by reiterating that the detection of cancers that would not progress to cause untoward symptoms or to ultimately cause the death of men diagnosed with prostate cancer has led to the perceived growth of  new diagnoses.

One of the two studies most relied upon by the task force was a European study that reported a small absolute reduction in prostate cancer mortality of less than 1 per cent or 13 lives saved per 10,000 men screened. The task force concluded that was too slim a benefit to outweigh the harms that flow from over diagnosing and over treating prostate cancers.

Dr. Finelli, chair of the guideline committee for the Canadian Urological Association, said his organization will keep backing the PSA test, despite the task force’s advice.

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