Prostate cancer screening should work better than it does. By measuring prostate specific antigen (PSA) levels in the blood, doctors should be able to detect prostate cancers before symptoms appear and get them treated before they become dangerous or deadly. That is the cornerstone notion of prostate cancer screening.
Prostate cancer screening is important for men who find that they have been identified with advanced PCa disease. If an annual PSA test had not identified a doubling of my PSA (PSADT), in all probability, I would be dead now. The big unanswered question in prostate cancer care and almost every other form of cancer is when did the cancer cells begin to aggressively mutate?
There are opinions that prostate cancer is a form of cancer with a thirty to forty year duration from start to it causing death. For a man whose aggressive prostate cancer begins to mutate while he is an adolescent, there is a good chance that without PSA monitoring that man would suffer an early painful death from the disease.
However, another man’s less aggressive prostate cancer might begin its maturation during his middle-age years, and if he is not having annual PSA monitoring, there is a statistical chance that this man will die with prostate cancer but not from the disease. Something else such as cardiac disease or another form of cancer such as lung cancer may kill him.
With circulating tumor liquid biopsies and better PSMA PET imaging, detection of prostate cancer within a man’s prostate gland at an earlier age might be detected before the prostate cancer has mutated and forced its way through and out of the prostate gland capsule and into the man’s vascular, lymphatic or nervous systems. Once the mutated prostate cancer cells have moved into those pathways, the cancer cells can travel through to the far reaches of the man’s body and become often a systemic incurable disease.
Early detection resulting from early testing and follow-up imaging is always a cost versus benefit analysis. It becomes most important for the patients with the aggressive cancer diseases seeking to make their ailments chronic instead of death sentences. This is something that medical economists and insurance actuaries discus during hospital budget debates, and the men with aggressive prostate cancer are never part of those debates. American medicine is a business first even though almost everyone tries to pretend and argue that it is not.
I'm a good friend of J. P. Dwyer (best man at my wedding 28 years ago), with whom I regularly discuss these issues, so I won't repeat his comments. My prostate cancer diagnosis was in 2001 (sudden rise in a low PSA, followed by a free PSA test that suggested cancer was likely), and judged to be aggressive based on reading of the slides by a Dana Farber pathologist. In my case radical prostatectomy was recommended (radiation was out because of other factors) after an endorectal MRI showed no apparent spread to lymph nodes. This was before even laparascopic procedure was available for the surgery, so yes indeed the treatment had a considerable negative effect on quality of life for a while. Recurrence after 4.5 years led to radiation of the prostate bed (80% the likely source, I was told - but I was in the other 20%). Years later, lung nodules could not be determined with certainty to be prostate metastases rather than primary lung cancer, so more surgery - they were prostate mets. (Not too often that a finding of metastatic prostate cancer is greeted with relief!) But PSA continued to rise, and when the doubling time suggested further intervention, docetaxel (chemo) plus leuprolide (hormone therapy) was initiated - definitely negative for quality of life, for a few months. After seven years, I've been moved to darolutamide, an androgen receptor inhibitor - within six months, PSA undetectable and leuprolide discontinued. Leuprolide suppresses testosterone; darolutamide just makes it unavailable to the cancer cells, and so far seems more effective. Was it all worth it? No way to tell - I'm still here, age 80, after 23 years of treatments, still active in research in my chosen field. -- An anecdotal tale: at the time I was diagnosed, there were seven other men at the college I worked at who were diagnosed with prostate cancer within a two-year period. We knew one another (and got to know each other better after diagnosis!), and kept in touch. One of us opted for what was then called "watchful waiting"; the others all chose some form of treatment (four chose surgery, as I did; two older men chose radiation). The one who chose watchful waiting apparently did not have very good monitoring, as he died in less than two years. One who chose surgery died after 19 years at age 83. Most of us are still going (I've lost touch with a couple, but their obituaries haven't appeared on the college web site), one having just turned 91 and published yet another book this year. Anecdotal, of course - David Keith's question might have something interesting to say about us. -- I can only second the desire for a better way to screen for prostate cancer, but until then, openness about the uncertainty is called for, so each man can make his own decision how to proceed (though inevitably one's physician's opinion will be a factor).
I've gotten burned with not screening high risk younger men--Black men in their 50's. I did hear Otis Brawley speak about 10 years ago about the lack of benefit-when he was involved with ACS. And having a family member with a very high family risk--likely BRCA related--it reminds me to individualize risk as best possible.
Prostate cancer screening is important for men who find that they have been identified with advanced PCa disease. If an annual PSA test had not identified a doubling of my PSA (PSADT), in all probability, I would be dead now. The big unanswered question in prostate cancer care and almost every other form of cancer is when did the cancer cells begin to aggressively mutate?
There are opinions that prostate cancer is a form of cancer with a thirty to forty year duration from start to it causing death. For a man whose aggressive prostate cancer begins to mutate while he is an adolescent, there is a good chance that without PSA monitoring that man would suffer an early painful death from the disease.
However, another man’s less aggressive prostate cancer might begin its maturation during his middle-age years, and if he is not having annual PSA monitoring, there is a statistical chance that this man will die with prostate cancer but not from the disease. Something else such as cardiac disease or another form of cancer such as lung cancer may kill him.
With circulating tumor liquid biopsies and better PSMA PET imaging, detection of prostate cancer within a man’s prostate gland at an earlier age might be detected before the prostate cancer has mutated and forced its way through and out of the prostate gland capsule and into the man’s vascular, lymphatic or nervous systems. Once the mutated prostate cancer cells have moved into those pathways, the cancer cells can travel through to the far reaches of the man’s body and become often a systemic incurable disease.
Early detection resulting from early testing and follow-up imaging is always a cost versus benefit analysis. It becomes most important for the patients with the aggressive cancer diseases seeking to make their ailments chronic instead of death sentences. This is something that medical economists and insurance actuaries discus during hospital budget debates, and the men with aggressive prostate cancer are never part of those debates. American medicine is a business first even though almost everyone tries to pretend and argue that it is not.
I literally cried tears of joy when I first saw those Kaplan-Meir curves from the COVID vaccine trials.
Do the results get any more interesting if broken down by age at diagnosis, stage at diagnosis, and treatment chosen?
I'm a good friend of J. P. Dwyer (best man at my wedding 28 years ago), with whom I regularly discuss these issues, so I won't repeat his comments. My prostate cancer diagnosis was in 2001 (sudden rise in a low PSA, followed by a free PSA test that suggested cancer was likely), and judged to be aggressive based on reading of the slides by a Dana Farber pathologist. In my case radical prostatectomy was recommended (radiation was out because of other factors) after an endorectal MRI showed no apparent spread to lymph nodes. This was before even laparascopic procedure was available for the surgery, so yes indeed the treatment had a considerable negative effect on quality of life for a while. Recurrence after 4.5 years led to radiation of the prostate bed (80% the likely source, I was told - but I was in the other 20%). Years later, lung nodules could not be determined with certainty to be prostate metastases rather than primary lung cancer, so more surgery - they were prostate mets. (Not too often that a finding of metastatic prostate cancer is greeted with relief!) But PSA continued to rise, and when the doubling time suggested further intervention, docetaxel (chemo) plus leuprolide (hormone therapy) was initiated - definitely negative for quality of life, for a few months. After seven years, I've been moved to darolutamide, an androgen receptor inhibitor - within six months, PSA undetectable and leuprolide discontinued. Leuprolide suppresses testosterone; darolutamide just makes it unavailable to the cancer cells, and so far seems more effective. Was it all worth it? No way to tell - I'm still here, age 80, after 23 years of treatments, still active in research in my chosen field. -- An anecdotal tale: at the time I was diagnosed, there were seven other men at the college I worked at who were diagnosed with prostate cancer within a two-year period. We knew one another (and got to know each other better after diagnosis!), and kept in touch. One of us opted for what was then called "watchful waiting"; the others all chose some form of treatment (four chose surgery, as I did; two older men chose radiation). The one who chose watchful waiting apparently did not have very good monitoring, as he died in less than two years. One who chose surgery died after 19 years at age 83. Most of us are still going (I've lost touch with a couple, but their obituaries haven't appeared on the college web site), one having just turned 91 and published yet another book this year. Anecdotal, of course - David Keith's question might have something interesting to say about us. -- I can only second the desire for a better way to screen for prostate cancer, but until then, openness about the uncertainty is called for, so each man can make his own decision how to proceed (though inevitably one's physician's opinion will be a factor).
I've gotten burned with not screening high risk younger men--Black men in their 50's. I did hear Otis Brawley speak about 10 years ago about the lack of benefit-when he was involved with ACS. And having a family member with a very high family risk--likely BRCA related--it reminds me to individualize risk as best possible.