The return of prostate cancer: A step backward

Sep 06, 2016

Urologist Henry Rosevear, MD discusses his thoughts on PSA screening and the recent increase in patients presenting with metastatic disease.

Henry Rosevear, MDUT

I wanted to title this blog about the return of prostate cancer, “I told you so,” but given the deadly seriousness of the topic, I didn’t think it was appropriate. Furthermore, while the recent data are only the latest to support my hypothesis, I’ll concede that the Nobel committee has yet to send me my invitation to Oslo. Yet.

What is my hypothesis? I hypothesize that as the rate of screening for prostate cancer (both by digital rectal exam and PSA) decreases, the stage of presentation of the disease will re-migrate and eventually return to what it was before any screening occurred. Sounds straightforward enough. Not screening does not cause the disease to vanish; the disease simply presents at a more advanced stage.

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What will the world look like when this new equilibrium is reached? All you have to do is look at the SEER data from the pre-screening era to form a clearer picture.

I think it’s important to remember why prostate cancer screening is such an important topic. While many contemporary physicians think of prostate cancer as a chronic disease-something that can and should be observed in the majority of men-it wasn’t always that way.

According to James L. Mohler, MD, of Roswell Park Cancer Institute, before PSA was common, the diagnosis of prostate cancer was equivalent to a death sentence. “Back then, only 4% of prostate cancers we diagnosed were curable. Now, with PSA, the cure rate is between 80% and 90%," Dr. Mohler said in an article on the Roswell Park website.

So I ask the question: Why are we taking a step backward? Why are we throwing away the best test that we currently have to screen for this disease?

Before anyone writes me, especially those of the opinion that PSA screening does not save lives (it does), let me take a moment to clarify. My hypothesis is simply that if we stop screening, more people will present with metastatic disease. But let’s save the conversation about the ability of PSA screening to save lives for another day.

Next: Why the increase in prostate cancer cases?

 

With that in mind, this June, Edward M. Schaefer, MD, PhD, and colleagues at Northwestern University published a paper showing that the number of new cases of metastatic prostate cancer increased by 72% between 2004 and 2013. Further, and most importantly, the largest increase (92%) was among men between age 55 and 69, the exact age group most likely to benefit from screening. When asked why, Dr. Schaeffer stated in a Northwestern press release, “One hypothesis is the disease has become more aggressive, regardless of the change in screening.”

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OK, that makes sense. Of course, anything is possible. It’s also possible that I will awake tomorrow morning 8 inches taller and with bigger biceps. Sure, it’s possible and as a good scientist, Dr. Schaeffer had to mention a spontaneous change in the disease as a possibility to explain his data.

He then continued, “The other idea is since screening guidelines have become more lax, when men do get diagnosed, it’s at a more advanced stage of disease.”

Bingo.

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Dr. Schaeffer is an educated urologist, and just as every urology resident is taught about how the rise in prostate cancer incidence in the ‘90s was related to the increased use of PSA, the recent decline in screening will cause an opposite effect.

Next: Response from the ACA

 

What surprised me most about this article was the sudden and vicious response by those groups advocating against the use of PSA. In an article from UPI, Otis Brawley, MD, chief medical officer of the American Cancer Society, said: "This study makes a dramatic claim about an issue all of us have been watching eagerly: namely, whether less PSA screening might lead to more advanced cancers. But the current analysis is far from adequate to answer that question sufficiently.

"But this study, done by a group of urologists, didn't do that." Dr. Brawley added.

He says the increase in advanced prostate cancer cases predates the 2012 U.S. Preventive Services Task Force recommendation of grade D for PSA, ignoring that the USPSTF has labeled it a “C” for years before that.

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Notice how Dr. Brawley added the phrase “done by a group of urologists”? Why is that important? Is he surprised that a group of physicians who have devoted their lives to men’s health, who are experts in diseases of the prostate, conducted research on prostate cancer? Or is he implying a bias in the research because of their background?

The current chairwoman of the USPTSF is a general internist from the University of California, San Francisco. I assume Dr. Brawley would argue she shouldn’t do hypertension research for the same reasons. Unless he was being flippant about this topic. And if this is the case, maybe Dr. Brawley should leave sarcasm to us small-town bloggers and stick to science instead. My statements don’t affect public policy, whereas his statements can cause men to die.

Or maybe Dr. Brawley should have listened to his own researchers. A recent paper published by researchers from the American Cancer Society, including Dr. Brawley, shows that the incidence of early-stage prostate cancer decreased by 6% between 2012 and 2013. Again, if you don’t look for early asymptomatic disease, you won’t find it.

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Prostate cancer is returning. The first hints of this are starting to appear in the literature. More will come as the data mature over time. As urologists, we need to not only educate our patients and colleagues on the dangers of under-diagnosis, but we need to support groups such as the AUA, LUGPA, and AACU, who are lobbying Washington to change this ridiculous and neglectful policy concerning men’s health.

If anyone else has experience with this situation or has an idea about how to best make our voices heard, please write me at UT@advanstar.com or sign in below to post a comment.

More from Dr. Rosevear:

My $4.07 check from an insurer: A sign of the Times

The transgender community: Urology has a role and responsibility

Marijuana and me: A Colorado urologist's experience