Many men come into our offices after their initial diagnosis or in the middle of their management of prostate cancer. For the newly diagnosed, they come in with lots of questions because the treatment or prostate cancer is confusing, conflicting and sometimes controversial. For the patient who is being treated with prostate cancer, they have already seen first hand how one doctor may suggest one thing and a second doctor may suggest another management program. These patients maybe upset and confused by their treatment, they have done some research and they have found our clinic.
There has been a great controversy in the last few years regarding the “over treatment” of prostate cancer.
“as many as 20-50% of men diagnosed could have remained asymptomatic in their lifetimes.” These men probably did not need many of the treatments they got
A July 2020 review in the journal Medical Sciences (1) gives this interpretation of the controversies in prostate cancer treatment.
The problem of over diagnosis and over treatment
“A rapid rise and then fall in prostate cancer incidence in the US and Europe corresponded to the implementation of widespread prostate specific antigen (PSA) testing in 1986 and then subsequent fall from favor due to high rates of false positives, overdiagnosis, and overtreatment (as many as 20-50% of men diagnosed could have remained asymptomatic in their lifetimes).
“Active surveillance or watchful waiting are appealing approaches for men diagnosed with low-risk prostate cancer. . . the antidote to over treatment.”
Doctors began to recognize that perhaps in some patients, over diagnosis and over treatment with surgery, hormonal therapies and tradition oncology was not helpful for many. This was recohnized in an October 2019 paper in the journal Diagnostics (2).
“Prostate cancer is one of the most common cancers in men that usually develops slowly. Since diagnostic methods improved in the last decade and are highly precise, more cancers are diagnosed at an early stage. Active surveillance or watchful waiting are appealing approaches for men diagnosed with low-risk prostate cancer, and they are an antidote to the overtreatment problem and unnecessary biopsies.”
Note that the research called the more conservative approach to helping men with prostate cancer the antidote to over treatment.
Certainly castration would be considered by some a controversial “over treatment.” Doctors write castration is often “used in patients who have little or nothing to gain.”
The most radical of possible over treatments is castration. In November 2018, a team of urologists from VA Ann Arbor Healthcare System and the University of Michigan wrote this in the journal Implementation science. (3)
“Many men with prostate cancer are castrated with long-acting injectable drugs (androgen deprivation). Although some patients benefit, it is also used in patients who have little or nothing to gain, such as men with localized prostate cancer. The best ways to stop, or de-implement, low value cancer care are unknown. A significant scientific and clinical knowledge gap remains in prioritizing which barriers to stopping castration in low value settings need to be targeted for effective de-implementation.”
The problem is what is obviously stated above, “The best ways to stop, or de-implement, low value cancer care are unknown.”
For the man with prostate cancer, his oncologists will discuss and may recommend “Hormone therapy.” This is also called androgen deprivation therapy (ADT) or androgen suppression therapy.”
The patients will be told that this treatment is being initiated to reduce his circulating levels of androgens or testosterone and dihydrotestosterone (DHT). This is necessary to stop these hormones from stimulating prostate cancer cells growth.
It should be pointed out this treatment is not considered a “cure,” for prostate cancer, it is part of a multi-pronged program against the disease.
Should prostate cancer be treated this aggressively?
The above research calls on a 2006 study from the Journal of the National Cancer Institute (4) from the University of Texas. This study from 12 years ago echos the same concerns of the November 2018 study.
“The use of androgen deprivation therapy for prostate cancer has been increasing, even in settings for which there is weak or no evidence of efficacy. This pattern suggests that factors other than the typical patient and tumor characteristics may be driving its use. ”
What was that factor determining the use of androgen deprivation? The urologist. “Which urologist a patient sees may be more important in determining whether they will receive androgen deprivation therapy.”
In other words, the urologist picked the treatment regardless of the individual need of the patient.
In 2010, a study reported in the New England Journal of Medicine (5), all cited in the above research suggests that there was a decline in the use androgen deprivation therapy, not because the treatment was at question, but because Medicare guidelines stopped covering it for men who did not need it.
Yet the inappropriate use of androgen deprivation therapy remains documented in the medical literature today.
“The best ways to stop, or de-implement, low value cancer care are unknown.”
The undisputed fact is that there is a need in the medical community to seek out and aggressively treat prostate cancer. You may be thinking to yourself, what is wrong with that? There is nothing wrong with that for patients who need aggressive care. Not all prostate cancer patients NEED aggressive care.
For more than 30 years we have offered and developed a “supportive care,” program at the Magaziner Center for Wellness for patients with a cancer diagnosis. Part of this support is in helping the patient understand their cancer and to help the patient with research to helps make informed decisions. Part of this program is designed to take the panic out of the diagnosis. Some cancer specialist think there is a lot of panic in prostate cancer diagnosis. This panic leads to an over treatment with low value cancer care.
Eyes on the PSA as the start of over treatment with low value care
Screening programs for prostate cancer based on the determination of serum prostate specific antigen (PSA) has led to over diagnosis, and consequently over treatment of Prostate cancer. This point, as made in the in the July/August 2017 edition of the medical publication Semergen (6), published in Spain, brings to light the question of how men with prostate cancer are treated, and if they should be “aggressively” treated.
From this study, we also learn that a percentage of men diagnosed with prostate cancer have a tumor that will not progress, or do so slowly (over diagnosis or pseudo-disease). This over diagnosis rate ranges from 17-50%.
This study also suggests that early detection or opportunistic screening involves the pursuit of individual cases being initiated by the doctor or the patient. In the case of a patient who requests a prostate specific antigen from their general practitioner, a number of issues on over diagnosis, over-treatment and possible damage from the biopsy, should be explained to him. With data from randomized studies on prostate specific antigen and prostate cancer screening, population screening is not recommended by any urological society.
“Some prostate cancers are so slow-growing that data suggests the risks of treatment may outweigh the benefits.”
Earlier a study from researchers at the University of Michigan published in the journal Health Affairs (7) confirmed that the overall rate of men receiving treatment for prostate cancer declined 42 percent. This was because national guidelines recommend against routine prostate cancer screening and patients and doctors are beginning to understand that there is an over treatment of prostate cancer occurring.
The Michigan researchers noted: “Some prostate cancers are so slow-growing that data suggests the risks of treatment may outweigh the benefits.” Watchful waiting or active surveillance (which involves monitoring patients without delivering treatment) are better options, especially for those patients with low-risk disease or limited life expectancy. By monitoring these patients, urologists can identify when treatment may become necessary.(8)
Prostate cancer, like all cancers is a complex disorder that affects each patient differently. Some patients do require an aggressive approach, some patients not. Our program emphasizes the concept of Thriving While Surviving. We strive to transform cancer from an acute disease into more of a chronic illness, one that can be lived with for many months or even years. Some of our patients have greatly outlived their life expectancy by even two or three-fold. Furthermore, most are able to continue with a productive and fulfilling life.
If you would like to explore more information, please contact our office so we can start a conversation with you.
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References
1 Barsouk A, Padala SA, Vakiti A, et al. Epidemiology, Staging and Management of Prostate Cancer. Med Sci (Basel). 2020;8(3):E28. Published 2020 Jul 20. doi:10.3390/medsci8030028
2 Malinowski B, Wiciński M, Musiała N, Osowska I, Szostak M. Previous, Current, and Future Pharmacotherapy and Diagnosis of Prostate Cancer-A Comprehensive Review. Diagnostics (Basel). 2019;9(4):161. Published 2019 Oct 25. doi:10.3390/diagnostics9040161
3 Skolarus TA, Hawley ST, Wittmann DA, Forman J, Metreger T, Sparks JB, Zhu K, Caram ME, Hollenbeck BK, Makarov DV, Leppert JT. De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT). Implementation Science. 2018 Dec;13(1):144.
4. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Determinants of androgen deprivation therapy use for prostate cancer: role of the urologist. Journal of the National Cancer Institute. 2006 Jun 21;98(12):839-45.
5. Shahinian VB, Kuo YF, Gilbert SM. Reimbursement policy and androgen-deprivation therapy for prostate cancer. New England Journal of Medicine. 2010 Nov 4;363(19):1822-32.
6 Jalón MA, Escaf BS, Viña AL, Jalón MM. Current aspects of prostate cancer screening. Semergen. 2016 Aug.
7 Tudor Borza, Samuel R. Kaufman, Vahakn B. Shahinian, Phyllis Yan, David C. Miller, Ted A. Skolarus, Brent K. Hollenbeck. Sharp Decline In Prostate Cancer Treatment Among Men In The General Population, But Not Among Diagnosed Men. Health Affairs, 2017; 36 (1): 108 DOI: 10.1377/hlthaff.2016.0739
8 Prostate cancer treatment rates drop, reflecting change in screening recommendations University of Michigan press release January 8, 2017
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