Prostate cancer

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Memo to men: talk to your doctor about testing

James Careless

©2012 Thinkstock

Prostate cancer is as common in men as breast cancer is in women. Starting at age 50, many thousands of symptom-free Canadian women are screened every two years in public mammography programs for possible breast abnormalities, and this screening is credited with saving lives. Similar widespread testing in middle-aged men for prostate cancer is controversial. Yet one in seven Canadian men will develop prostate cancer during his lifetime. Men with a family history of prostate cancer and men of African ancestry are at a higher level of risk than the general population — but all men are vulnerable, mainly after age 60.

Until recently, early detection through PSA screening was touted as the best way to fight prostate cancer. PSA is the acronym for prostate specific antigen, a protein produced by the prostate that helps keep semen in liquid form, and prostate cancer cells typically release more PSA into the bloodstream than healthy cells. (PSA levels can also rise with an enlarged prostate, a benign condition.) Recently, a report from the U.S. Preventive Services Task Force (USPSTF) has cast doubt on this detection approach.

Although the USPSTF agreed that PSA screening of healthy, symptomfree men “can detect some cases of prostate cancer,” it found “inadequate evidence to determine whether treatment for prostate cancer detected by screening improves health outcomes compared with treatment after clinical detection” for men age 75 and younger. In other words, PSA-testing healthy men with no prostate symptoms works no better than waiting until a man has genitourinary problems and then gets tested by his doctor. (Find the full report at www.uspreventiveservicestaskforce.org.)

Meanwhile, in men age 76 or older, the USPSTF found that “the incremental benefits of treatment for prostate cancer detected by screening are small to none.”

So what do Canadian researchers think of the USPSTF’s conclusions? “I think this is a bit too negative,” replies Richard P. Gallagher, an emeritus scientist with the BC Cancer Agency’s Cancer Control Research program in Vancouver, who points to a study that found fewer deaths with PSA screening. “The fact is that the European Randomized Trial of Screening for Prostate Cancer with PSA showed a reduction in mortality from prostate cancer of about 20% in men who were in the PSA arm of the trial,” he says. “This is fairly substantial and may actually increase as follow-up of the men in the trial continues.”

“Early detection is still important for heading off prostate cancer. If you are not testing for prostate cancer, you are not likely to find it until it has developed substantially”

Each year, 25,500 Canadian men are diagnosed with prostate cancer, says Gallagher, and 4,100 die of it. Often, however, prostate cancer is slow-growing and doctors may recommend an “active surveillance” approach in which treatment is deferred unless changes in the tumour suggest that it is becoming more aggressive. For men who proceed to treatment, options such as chemotherapy, hormone therapy, surgery or radiation can result in undesired effects such as erectile dysfunction, urinary incontinence and bowel problems.

Broad screening programs aside, should individual men stop asking their doctors about being tested for prostate cancer? In Canada, the answer is no. “Early detection is still important for heading off prostate cancer,” says Dr. Robert Nam, head of genitourinary cancer care at Toronto’s Sunnybrook Health Sciences Centre. “If you are not testing for prostate cancer, you are not likely to find it until it has developed substantially.”

Adds Gallagher, “The reason for discussion with your doctor is that you can then look at the balance of risks and benefits and determine if the PSA test is for you. Without this, you may not get the full picture of what the test implies.”

The Canadian approach to prostate cancer detection goes beyond PSA screening, which is done via a blood test. “In fact, we combine PSA testing with information about the patient’s age, overall health, ethnic background and whether or not his family has a history of prostate cancer,” says Nam. You can find Sunnybrook’s Prostate Cancer Risk Calculator at http://prostaterisk.ca. The Canadian approach also uses the online quiz at www.prostatecancer.ca to assess the patient’s risk for developing the disease.

“Only when we look at all these factors, plus do a digital rectal exam, or DRE, with suspicious results confirmed by biopsy, do we then consider treatment options — in discussion with our patients,” says Nam. In a DRE, the doctor puts on a latex glove and inserts a finger into the patient’s rectum to physically check the prostate gland for size, tenderness and nodules — or anything else that is out of the ordinary.

Rod Seiling is one Canadian who believes in PSA testing. Now chair of the Ontario Racing Commission, Seiling is a former NHL star defenceman who played for the New York Rangers, among other teams. “I’m living proof that PSA screening can detect prostate cancer while it is still treatable,” Seiling says. “You just have to look for it, face it and deal with it.”

Canadian double Olympic gold medal swimmer Alex Baumann is another prostate cancer survivor. “I’m here today because my doctor noticed that something might be wrong and had me thoroughly tested,” says Baumann. Asked about the concerns raised by the USPSTF, he replies, “Of course, I am not a specialist, but I believe in the test. At this point in time, while somewhat flawed, this test is still effective in establishing a means of tracking potential prostate problems.” One thing is certain: Baumann credits PSA testing for ultimately saving his life. “Once my diagnosis of cancer was confirmed by biopsy, the results showed that more than half my prostate was cancerous,” he says.

The debate over PSA screening is just that — a debate by learned physicians on both sides of the question, all trying to find the right answers for their patients. But what is not at issue is the pervasiveness of prostate cancer among men. Among its better-known survivors are Nelson Mandela, General “Stormin’ Norman” Schwarzkopf, Colin Powell, Rudolph Giuliani, Arnold Palmer, Harry Belafonte, Robert De Niro, Roger Moore and Archbishop Desmond Tutu. On the tragic side, those bright lights whose prostate cancer was not detected in time include Jerry Orbach, Frank Zappa and Pierre Elliott Trudeau.

The bottom line? Prostate cancer is a serious threat to men’s health and something that men age 50 and over need to discuss with their doctors. “Whether you choose to be tested or not is up to you,” says Nam. “But the discussion about prostate cancer needs to take place.”