It’s been a big couple months of headlines in the news for prostate cancer. I’m a prostate cancer survivor and cancer biologist so I spend probably more than my share of time thinking about prostate cancer and from a number of angles. A few days ago I got a test result suggesting I’m still in long-term remission so I’m happy, but prostate cancer is on my mind.
Another big headline came out today suggesting prostate cancer surgery for men diagnosed with the disease may in many cases be unnecessary or harmful.
Let me help you make sense of all the prostate cancer news.
Let’s try to be as logical as Spock from Star Trek. 
Prostate cancer seems almost an inevitable fate for men in America and for many other men around the world if you live long enough, but a significant fraction of the cancers are not life threatening.
Others, unfortunately such as the cancer I had surgery for 2 1/2 years ago (read my cancer “coming out” post here), are to the contrary very serious.
No watchful waiting for these.
Many questions remain about prostate cancer….
- How good are we at telling the difference between relatively tame cancers and the tiger-like cancers that eventually kill a substantial fraction of those who have them?
- What’s the best way to detect the cancers that are dangerous?
- How can we best help men with prostate cancer?
- What about those men whose cancer has recurred?
These questions are just a handful of the many important ones out there and it can be confusing.
What’s the scoop on the latest headlines?
First there was the bombshell that the federal task force recommended that all PSA testing be stopped. They claimed that PSA testing did more harm than good. Most rational people who are well-educated about prostate cancer that I have talked to in the biomedical community think the task force made a huge mistake. As I put it, they threw the baby out with the bathwater. It is not time to abandon PSA testing, but rather a prime opportunity to refine it and adopt a more logical system of testing. Bottom line, I think men should still get tested but guided by something similar to the new guidelines that I’ve proposed. At risk men such as those with a first degree relative who has had prostate cancer (e.g. my two brothers), especially at a young age, should get tested.
Second, we heard promising news that J&J’s drug Zytiga (Abiraterone) worked so well in a trial that the trial was stopped so all men could receive the treatment. Very encouraging news. Zytiga works by inhibiting production of testosterone. It is intended to be used for so called hormone resistant prostate cancer (which is the form of prostate cancer that kills men) for which older drugs no longer work. Zytiga has shown promise both for treatment of men with prostate cancer prior to their surgery (shrinks tumor before removing prostate) AND later in the course of the disease. Bottom line, Zytiga is just one of numerous new prostate cancer drugs in the pipeline so the fact that it works well is good news. Fans of another prostate cancer therapy, Provenge, which involves the use of immune cells and costs $100K, have nit-picked at issues related to Zytiga, but overall I think Zytiga is much more promising personally.
Third, it was reported that taking breaks from hormone-deprivation therapy may increase mortality. Let me explain. One of the weapons against prostate cancer is treatment of patients with drugs that block production of testosterone because testosterone is like fuel for prostate cancer. However, inevitably cancers find a way to become resistant to the anti-testosterone therapy. Nonetheless hormone deprivation is an important tool and can keep cancer at bay for years. One such drug is called Lupron. The catch is that Lupron has very nasty side effects.
My father, who had prostate cancer at age 58 and then had a recurrence about a couple decades later, took Lupron for a time. He hated it. Most men do hate Lupron and hence the impetus for wanting to take a break now and then from getting the hormone deprivation therapy. Now scientists report that taking such breaks, which helps alleviate the nasty side effects of the drug, has a cost: men taking breaks from hormone deprivation therapy are more likely to have their cancer be worse. Bottom line, this is not unexpected, but is still bad news that if men want the max benefit from anti-hormone therapies they are going to have to put up with the side effects without breaks.
Fourth, today a study was reported in the NY Times and published in the NEJM that suggested for many men prostate cancer surgery may be unnecessary or harmful. What does this mean? The study was a small one looking at 731 men with prostate cancer, but it suggests that for men with apparently lower risk prostate cancer and lower PSA levels that prostate surgery (prostatectomy) may not be beneficial. However, there were benefits of surgery to men with higher PSA levels at diagnosis (10ng/ml or higher) and the findings suggesting little benefit of surgery did not apply to men with apparently higher risk cancer. In addition fewer men who got surgery overall died during the 15 year study, but the difference was not statistically significant.
OK, so what would Spock make of all this?
I think he’d be favor of continuing PSA testing, but in a more logical manner. Don’t throw out the PSA testing system entirely, but rather make it better and more logical.
I believe he’d be encouraged by the news on the drug front and he’d advocate taking no breaks from hormone deprivation even if the side effects are nasty.
Spock would be in favor of more study of the benefits and risks of prostate cancer surgery before drawing a conclusion, but perhaps would encourage more watchful waiting amongst men who have apparently lower risk cancer.
Maybe Spock could invent a way to beam cancer out of the body!
Note, a version of this piece was originally published by me at Science2.0
It has been observed repeatedly across disciplines that hormonal or neuro-transmitter irregularities are consistent with higher neuro-degeneration and malignacy rates. Unfortunately simply plugging that hole has not demonstrated a consistent fix for the problem long term. The hormone imbalance etc is the result not the root of the underlying problems
The same reports condemn breast cancer screening and colon giving too many numbers needed to treat and false positive harm, in a depressed economy that is a trend. What is overlooked is what we have learned from screening, long term like 30 instead of 5 year survival rates and the need for more money and focus on accurate diagnosis and differentiations of types of cancers so interventions can be accurately targeted and developed for the condition rather than painting all with the same C brush.
Also screening raises awareness, a close relative went for mammography because she felt uneasy, the tumor was rare, aggressive and undetectable by regular examination. Prompt surgery saved her life and she is now cancer free. Better follow up and education needs to accompany a positive and false positive diagnosis, patients are needlessly left unsupported and filled with fear. It would be great to have the critics work out how to do this right and add to the body of knowledge rather than subtract from it. Congratulations on the clean results Paul, you have much to contribute and as brutal as cancer can be we are much happier with you alive than dead!
I see another side to this controversy. These “Stop PSA” and “Treatment does more harm than good” studies compare doing nothing with surgical outcomes. If there were a better treatment option for early PCa, with happier side-effects, most of the controversy would go away.
There is. I had a rapidly-rising PSA following a long history of an essentially stable PSA, followed by a biopsy with a Gleason 3+3=6 score. After a few weeks of research, I chose proton beam therapy (PBT). There was no change in any of my prostate-related activity during or after treatment, aside from a slight worsening of BPH symptoms controlled with Triazolam, and mild radiation proctitis deemed to require no treatment.
PBT is controversial because of its cost, limited availability, and the lack of any large-scale “proper” clinical trial data. A lot of my research consisted of talking with survivors of the various trreatments I was considering, and PBT came out the clear winner. While most survivors of all therapies were glad to be alive, PBT survivors were enthusiastic, as am I.
Unfortunately, PBT is often lumped in with other forms of photon radiation treatment when reporting outcomes, and thus gets tarred with an undeserved bad brush. It will be many years before the surviving PBT population is large enough that our numbers will yield meaningful statistics in terms of outcomes. In fact, by that time, other breakthrough therapies may prove to be superior in all respects, but for now I’m very happy with my choice, and regret that so many men go under the knive, steel or otherwise, and contribute to the bad outcomes now used to bad-mouth PSA testing, which, while imperfect, is a hell of a lot better than nothing.
Paul, what are your thoughts on this study? See http://www.sciencedaily.com/releases/2011/04/110419121353.htm. There’s a growing contingent of urologists who believe that the Testosterone story is much more complex than the “gas on fire” analogy. Basically that declining Testosterone in middle aged guys is one thing that can lead to a higher risk of prostate cancer. While pushing it still lower can improve outcomes, normalizing it may also either be neutral or improve outcomes. Basically, there may be value in a normal supplemented testosterone level that is equal to that of an artificially suppressed one. Thoughts?