Urologists Condemn Task Forces Anti-PSA Testing Stance

The U.S. Preventive Services Task Force (USPSTF) on May 21 released its final recommendations on PSA-based screening forprostate cancer (PCa), which advises against the practice and gives it a grade D rating, meaning the task force believes there is “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefit.”

Since the introduction of PSA screening in the United States, the PCa death rate has decreased by more than 40% and the percentage of men who have distant metastases and incurable disease at the time of diagnosis has decreased by 75%. In addition, he noted that statistical teams at the National Institute of Health concluded that up to 70% of these results are attributable directly to PSA testing.“We think that men should be made aware and offered an opportunity to make an informed decision for themselves,” Dr. Catalona said. “The PSA test provides very powerful predictive information about a mans risk for prostate cancer.”

via Urologists Condemn Task Forces Anti-PSA Testing Stance – Renal and Urology News.

The government has recently issued a recommendation against prostate cancer screening.   The panel that issues this recommendation did not have a single urologist, radiation oncologist, or medical oncologist on the panel.

I agree with some of the conclusions of the task force that men often undergo negative prostate biopsies, which have a risk of infection and bleeding and are uncomfortable.  Negative biopsies cause anxiety without a cancer diagnosis.  It is also true that men are sometimes treated for cancers that may never cause them symptoms.

The benefits of screening were not given significant consideration.  Prostate cancer still kills men and screening does save lives.  Metastatic prostate cancer causes significant pain and its treatment, hormonal therapy causes long term side effects such as osteoporosis and decreases quality of life.

The other change has been the decreasing morbidity to treat prostate cancer.  Most men that have early stage prostate cancer are cured with surgery, but most of them have full return of urinary function.  The advantage of having surgery are a decrease in long term BPH (benign prostate growth) symptoms.  As men get older, they have increasing frequency, nocturia (urinating at night), slowing stream, and a hesitancy (difficulty in starting to urinate).  After surgery, men have a strong stream that does not change as they age.  The morbidity that panel looked at from treatment was worse than patients would face today.

 

PCa Patients on HD Would Benefit from Early Kidney Transplantation – Renal and Urology News

However, study findings presented at the National Kidney Foundation 2012 Spring Clinical Meetings suggest that patients with prostate cancer (PCa) might be better served by undergoing transplantation instead of waiting two years to be declared cancer-free.

via PCa Patients on HD Would Benefit from Early Kidney Transplantation – Renal and Urology News.

 

This study looked at patients how had prostate cancer diagnosed within 6 months after transplantation.  Most patients were doing well after 2 years.  This is relevant since patients on dialysis need to wait 2 years after having surgery for cancer to be disease free prior to transplantation.  The risk to patients of being on hemodialysis for 2 years is higher than the risk of having prostate cancer in a transplant patient.  Studies like this should be done to see if patents with certain cancers, like kidney and prostate, may not need to wait the 2 years that they traditionally have.

Prostate-Cancer Mortality at 11 Years of Follow-up — NEJM

After a median follow-up of 11 years in the core age group, the relative reduction in the risk of death from prostate cancer in the screening group was 21% rate ratio, 0.79; 95% confidence interval [CI], 0.68 to 0.91; P=0.001, and 29% after adjustment for noncompliance. The absolute reduction in mortality in the screening group was 0.10 deaths per 1000 person-years or 1.07 deaths per 1000 men who underwent randomization. The rate ratio for death from prostate cancer during follow-up years 10 and 11 was 0.62 95% CI, 0.45 to 0.85; P=0.003. To prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected. There was no significant between-group difference in all-cause mortality.

via Prostate-Cancer Mortality at 11 Years of Follow-up — NEJM.

This NEJM published study is a 2 year update from the European Randomized Study of Screening for prostate cancer.  This is a timely article given the debate in this country as to the utility of prostate cancer screening.

Prostate cancer is a slow growing cancer that rarely cause mortality in months.  As more time goes by I would expect the updated version of this study to show a larger amount of people being helped by the treatment of their prostate cancer.

5-ARI delays prostate cancer progression in men with low-risk disease – ModernMedicine

The 5-alpha-reductase inhibitor dutasteride Avodart appears to delay disease progression and the initiation of active treatment in men with low-risk, localized prostate cancer, results of a 3-year international clinical trial indicate.Treatment with dutasteride also reduces cancer-related anxiety, study authors found.”The results prove that using active surveillance plus dutasteride is a viable, safe, and effective treatment option for men who often undergo aggressive local treatment despite low risk of dying from the disease,” said first author Neil Fleshner, MD, of the University of Toronto’s Princess Margaret Hospital.

via 5-ARI delays prostate cancer progression in men with low-risk disease – – ModernMedicine.

This is the first study I’ve seen that shows that 5-alpha-reductase inhibitors may help slow the progression of prostate cancer.  These medicines are tolerated well by most patients and treatment with avodart can be considered.

Statins During Radiotherapy for High-Risk Prostate Cancer Improve Outcomes – Renal and Urology News

Statins During Radiotherapy for High-Risk Prostate Cancer Improve Outcomes

via Statins During Radiotherapy for High-Risk Prostate Cancer Improve Outcomes – Renal and Urology News.

Statins are medicines that are taken to lower cholesterol.  Many studies have shown they are beneficial in preventing heart disease and many diseases.  Some experts believe that these medicines help prevent prostate  cancer and this study shows that patients with HIGH risk prostate cancer receiving radiation therapy had a better result when they were on statins.

 

Radiotherapy and Short-Term Androgen Deprivation for Localized Prostate Cancer — NEJM

Among patients with stage T1b, T1c, T2a, or T2b prostate adenocarcinoma and a PSA level of 20 ng per milliliter or less, the use of short-term ADT for 4 months before and during radiotherapy was associated with significantly decreased disease-specific mortality and increased overall survival. According to post hoc risk analysis, the benefit was mainly seen in intermediate-risk, but not low-risk, men. Funded by the National Cancer Institute; RTOG 94-08 ClinicalTrials.gov number, NCT00002597.

via Radiotherapy and Short-Term Androgen Deprivation for Localized Prostate Cancer — NEJM.

 

This study revealed a reduction in overall survival at 10 years and disease-specific mortality at 10 years.  Patients studied were low and moderate risk prostate cancer patients receiving radiotherapy as definitive therapy.

Only the moderate risk patients were shown to have a benefit.

Short-term neoadjuvant androgen deprivation and radiotherapy for locally advanced prostate cancer: 10-year data from the TROG 96.01 randomised trial.

INTERPRETATION: 6 months of neoadjuvant androgen deprivation combined radiotherapy is an effective treatment option for locally advanced prostate cancer, particularly in men without nodal metastases or pre-existing metabolic comorbidities that could be exacerbated by prolonged androgen deprivation.

via Short-term neoadjuvant androgen deprivation and radiotherapy for locally advanced prostate cancer: 10-year data from the TROG 96.01 randomised trial..

 

This study shows that men that are undergoing radiation therapy for prostate cancer had a benefit by adding 6 months of hormonal therapy compared to no hormonal therapy.

Statins make radiation more effective at curing prostate cancer, study suggests

Statins Make Radiation More Effective at Curing Prostate Cancer, Study Suggests

ScienceDaily (Mar. 25, 2011) — Men with high-risk prostate cancer who take statin drugs commonly used to lower cholesterol while receiving radiation therapy are less likely to have their cancer return than patients who do not take these medications, according to a study published in the March issue of the International Journal of Radiation Oncology•Biology•Physics, an official journal of the American Society for Radiation Oncology (ASTRO).

via Statins make radiation more effective at curing prostate cancer, study suggests.

Statins are a class of cholesterol lowering medicines that have been shown to prevent many diseases including heart disease.

There have been studies that show a benefit in prostate cancer prevention and recurrence rates.

A friend of mine, and in my opinion the world’s leading authority on clinical applications of supplements and medicines for prostate cancer prevention, Dr. Mark Moyad, is in the process at looking at statins in patients on active surveillance for prostate cancer to see if it will slow the progression of disease in these patients.

Added Radiation to ADT May Improve Survival – Renal and Urology News

Men with locally advanced prostate cancer (PCa) have a better chance of survival when they add radiation therapy (RT) to their hormone therapy, according to research presented at the 52nd annual meeting of the American Society for Radiation Oncology.

via Added Radiation to ADT May Improve Survival – Renal and Urology News.

This is another study that finds a survival advantage in adding radiation therapy to hormonal therapy in advanced prostate cancer.  Traditionally, urologists treated these patients with hormonal therapy only since radiation was not curative.

Newer studies are showing that external beam radiation added to hormonal therapy helps people live longer.  I think this is because radiation therapy is safer than it was in the past and treating the primary tumor may help prevent future metastases.

The Prognostic Impact of Seminal Vesicle Involvement Found at Prostatectomy and the Effects of Adjuvant Radiation

Source: Urotoday

Patients with seminal vesicle positive disease who received adjuvant radiation compared to observation realized an improvement in 10-year biochemical failure-free survival from 12% to 36% (p = 0.001), in 10-year overall survival from 51% to 71% (p = 0.08) and in metastasis-free survival from 47% to 66% (p = 0.09), respectively.

Although seminal vesicle involvement is a negative prognostic factor, long-term control is possible especially if patients are given adjuvant radiation therapy. This therapy appears to be effective in patients with seminal vesicle involvement.


This one study showed an advantage of giving patients radiation if they had cancer in the seminal vesicles at the time of radical prostatectomy. Many factors need to be addressed in determining if radiation is necessary after surgery.

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