“They look like glowing jade necklaces of such unearthly brilliance they could be a Ming emperor’s. But if Dr. Gerardo Fernandez is right, the green fluorescent images of prostate cells could be even more valuable, at least to the thousands of men every year who unnecessarily undergo aggressive treatment for prostate cancer.
“That’s because the glimmering images promise to show which prostate cancers are destined to remain harmless for the rest of a man’s life, and thus might spare many patients treatment that can cause impotence and incontinence.”
“In the UK ProtecT trial reported in TheNew England Journal of Medicine, Freddie C. Hamdy, FRCS, FMedSci, of the University of Oxford, and colleagues found no significant differences in prostate cancer–specific or overall mortality among men with clinically localized prostate cancer detected by prostate-specific antigen (PSA) testing who underwent active monitoring, surgery, or radiotherapy. Metastases and disease progression were more common with active monitoring. Median follow-up in the study was 10 years.”
“About a dozen new medical tests are coming to market that aim to more accurately diagnose prostate cancer and go well beyond the standard PSA (prostate-specific antigen) blood screenings used today. Several of them may even allow men to forego getting a biopsy that more than 1 million men diagnosed with prostate cancer undergo each year. That’s because these new tests will help doctors distinguish between aggressive disease and slow-growing tumors.”
When I was in my ’30s, I worked as a medical writer at the Chicago Sun-Times. I occasionally wrote articles about the troublesome prostate gland.
Here’s what I knew about the prostate:
A normal healthy gland is about the size of a walnut.
Older men often have enlarged prostates that cause them to wake up frequently at night to urinate. (I once overheard my father and father-in-law quietly discussing how their prostates kept them up at night.)
Advanced prostate cancer could spread into the bones and cause unbearable pain.
In most cases the disease grows slowly, which means men typically died with, but not from prostate cancer.
What did I know about my own prostate? Again, not much.
“A blood test called the 4Kscore results in accurate detection of high-grade prostate cancer. In a prospective study of 1,012 men, this test more accurately predicted the presence of high-grade disease compared with a commonly used risk calculator in men with elevated prostate-specific antigen (PSA) levels.
“The results from this study (Abstract 1) were presented by Sanoj Punnen, MD, a urologic oncologist at the University of Miami in Florida at the 2015 Genitourinary Cancers Symposium.
“In this study, men scheduled for a prostate biopsy were enrolled, regardless of their PSA level or clinical findings, at 26 centers across the United States between October 2013 and April 2014. A total of 231 (23%) high-grade prostate cancers were detected. The 4Kscore showed a higher net benefit in comparison with the PCPTRC at all threshold possibilities for high-grade disease used in clinical practice.
“The test is able to detect aggressive prostate cancer with high accuracy, Punnen told Cancer Network. ‘The area under the curve is better than any other biomarker in this area. There was a significant reduction in biopsies that could be attained if we used this test,’ he said.
“The goal of the 4Kscore is to reduce unnecessary biopsies, as the vast majority of biopsies show either no cancer or a low-grade tumor. These biopsies result in high medical costs, as well as morbidities for the patient.”
“Only 17 percent of top-ranked consumer health websites advise against screening for prostate cancer, a recommendation made more than two years ago by the U.S. Preventive Services Task Force (USPSTF), according to a study presented at the 2014 Clinical Congress of the American College of Surgeons.
“In an Internet search for the phrase ‘prostate cancer screening’ on three main U.S. search engines, study researchers found that most sites appearing on the first results page recommended a patient-individualized approach to screening.
“Prostate cancer is the most common cancer in men besides skin cancer, affecting one in seven American men over their lifetime according to the American Cancer Society.1 Screening, which is routine testing in the absence of symptoms, can detect prostate cancer early. Screening tests for this cancer are the prostate-specific antigen (PSA) blood test, a digital rectal exam, or both.
” ‘The recommendation not to screen men for prostate cancer is controversial,’ said lead author Philip Zhao, MD, a urologist at The Arthur Smith Institute for Urology at North Shore–Long Island Jewish Health System, New Hyde Park, N.Y. He performed the research while a resident physician at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J, under the guidance of Robert E. Weiss, MD, professor of urology.
” ‘Our study results suggest that two-thirds of the online community disagree with the USPSTF recommendation against prostate cancer screening,’ Dr. Zhao said.”
“A new Canadian guideline recommends that the prostate-specific antigen (PSA) test should not be used to screen for prostate cancer based on evidence that shows an increased risk of harm and uncertain benefits. The guideline is published in CMAJ (Canadian Medical Association Journal)
” ‘Some people believe men should be screened for prostate cancer with the PSA test but the evidence indicates otherwise,’ states Dr. Neil Bell, member of the Canadian Task Force on Preventive Health Care and chair of the prostate cancer guideline working group. ‘These recommendations balance the possible benefits of PSA screening with the potential harms of false positives, overdiagnosis and treatment of prostate cancer.’
“For men with prostate cancer diagnosed through PSA screening, between 11.3% and 19.8% will receive a false-positive diagnosis, and 40% to 56% will be affected by overdiagnosis leading to invasive treatment. Treatment such as surgery can cause postoperative complications, such as infection (in 11% to 21% of men), urinary incontinence (in up to 17.8%), erectile dysfunction (23.4%) and other complications.”
“As prostate cancer awareness month just ended, prostate cancer screening seemed a fitting subject for this week’s blog.
“Those who know the evidence might think this argument pits European practices against our own domestic actions. Almost like a Ryder Cup for prostate screening. However, I recently saw that almost 50% of patients admit to undergoing lubed finger insertions and blood tests, which we know to be fairly inaccurate, in the last 12 months.
“In a Research Letter in JAMA Internal Medicine by Sammon et al., the fact that so many physicians are still screening for prostate cancer makes my evidence-based medicine soul cringe. In a 2012 survey, the authors found that among 114,544 respondents, 37% had undergone screening. Higher socioeconomic status nearly doubled a man’s odds of being screened (odds ratio 1.91, 95% CI 2.69-3.34).
“Prostate cancer patients whose tumors contain a shortened protein called AR-V7, which can be detected in the blood, are less likely to respond to two widely used drugs for metastatic prostate cancer, according to results of a study led by researchers at the Johns Hopkins Kimmel Cancer Center. If large-scale studies validate the findings, the investigators say men with detectable blood levels of AR-V7 should avoid these two drugs and instead take other medicines to treat their prostate cancer. A report on the work is described online Sept. 3 in the New England Journal of Medicine.
“The study evaluated two groups of 31 men with prostate cancer that had spread and whose blood levels of prostate-specific antigen (PSA) were still rising despite low testosterone levels. Investigators gave each man either enzalutamide (Xtandi) or abiraterone (Zytiga) and tracked whether their PSA levels continued to rise, an indication that the drugs were not working. In the enzalutamide group, none of 12 patients whose blood samples tested positive for AR-V7 responded to the drug, compared with 10 responders among 19 men who had no AR-V7 detected. In the abiraterone group, none of six AR-V7-positive patients responded, compared with 17 responders among 25 patients lacking AR-V7.
“Enzalutamide and abiraterone have been very successful in lengthening the lives of about 80 percent of patients with metastatic prostate cancer, says Emmanuel Antonarakis, M.D., assistant professor of oncology at Johns Hopkins, but the drugs do not work in the remaining 20 percent of patients.
” ‘Until now, we haven’t been able to predict which patients will not respond to these therapies. If our results are confirmed by other researchers, a blood test could use AR-V7 as a biomarker to predict enzalutamide and abiraterone resistance, and let us direct patients who test positive for AR-V7 toward other types of therapy sooner, saving time and money while avoiding futile therapy,’ says Antonarakis.”