April 18, 2012

Buffett’s Prostate Cancer
Is Not a Death Knell

Louis Kavoussi, MD

Warren Buffett has announced to shareholders that he has the most common cancer in men, Stage 1 prostate cancer.

The information he released is insufficient to determine prognosis let alone what treatment is needed, if any. However, statistics are generally on Mr. Buttett’s side.
 
Autopsy studies show that most men will eventually present with prostate cancer. The good news is that the vast majority of them don't succumb to the disease--even without treatment.
 
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March 23, 2012

Controversy Persists About Prostate Cancer Screening

Manish Vira, MD

In 2009, the publication of the results of two large screening studies ignited the controversy over prostate-specific antigen (PSA) testing and prostate cancer screening. Now, both studies have been updated and the debate continues.

This month, the New England Journal of Medicine published an update of the European Randomized Study of Screening for Prostate Cancer (ERSPC) with two additional years of follow-up. The study reported a 21 percent reduction in prostate cancer mortality for participants screened with PSA testing. In the 10th and 11th year of follow-up, the mortality reduction in the screened cohort improved to 38 percent.
 
On the other hand, an update from the National Cancer Institute’s original report of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial now with follow up of 13 years continued to find no difference in prostate cancer mortality in study participants who were screened.
 
So we have conflicting recommendations from the two largest prostate cancer screening trials. While the debate about the overall benefit of screenings may continue, we can still draw helpful conclusions from these two trial updates.
 
First, it appears that patients can derive the potential benefits from PSA testing by getting screened every two years rather than annually. Second, it takes at least 10 years of follow-up to show the potential benefits of screening. This means that screening will probably not help older men with other significant medical issues. In fact, PSA testing may even cause significant harm from prostate biopsy complications and overtreatment of prostate cancer.
 
Still, given that the overwhelming majority of patients believe that cancer screening is important to good health, PSA testing is unlikely to diminish. Therefore, physicians should try to reduce the burden of overtreatment by increasing active surveillance in men with low-risk prostate cancer. Full Post - to Detail View

November 02, 2011

Radiation Increases Survival of ADT-Treated Prostate Patients

Louis Potters, MD

The latest Lancet outlines the results of a large Phase III clinical trial that shows that men with locally advanced prostate cancer (that has not spread elsewhere) who receive radiation therapy on top of their androgen deprivation therapy (ADT) have greater overall survival compared to men on ADT alone.

Data suggests that the use of hormones without radiation therapy to manage men with high-risk prostate cancer has increased in the past several years. The results of the Warde study tell us that radiation therapy needs to be added as a component of care for these men.

Using newer technology such as intensity modulated radiation and image guidance, higher doses of radiation therapy can safely be delivered in high-risk patients. Yet using older technology and lower radiation doses than today’s standards, the authors demonstrated a remarkable 90 percent disease-specific survival for men with very high risk disease. Plus, these survival gains were achieved without any clear decrease in overall quality of life.

Based on high-level evidence, radiation therapy is saving lives of men with prostate cancer. Though other methods of treating high-risk prostate cancer exist, a radiation-based approach remains the standard against which other modalities needed to be measured. Randomized trials comparing different treatments are required to test if these other methods will be equally efficacious to radiation therapy.

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October 31, 2011

Testosterone Preserves Muscle in Older Men

Stuart Weinerman, MD

Older men with higher testosterone levels lose less lean muscle mass as they age, according to a recent study accepted for publication in the Endocrine Society's Journal of Clinical Endocrinology and Metabolism. In the study of 1,183 men aged 65 years or older, higher testosterone levels were also associated with less loss of lower body strength.

While the study confirms that higher blood levels of testosterone in older men is associated with less of the loss of muscle mass that occurs with aging, there are several qualifications in the interpretation of the data. It was a prospective epidemiological study, which means it followed the group over time to address this specific question--so other variables may exist. For example, patients with low testosterone were more likely to have diabetes. Also, there was very little correlation with functional outcomes such as measures of strength, except in subgroup analysis conducted afterward.

Finally, this study should not be interpreted as evidence that men who have a decline or deficiency in testosterone production should begin testosterone replacement. The risks and benefits of testosterone replacement can only be studied in larger, randomized controlled trials, which are the most rigorous way to determine whether a cause/effect relation exists between treatment and outcome.

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October 10, 2011

Making Sense of Prostate Cancer Screening

Lee Richstone, MD
Manish Vira, MD

This past week, it was hard to escape hearing news regarding the US Preventive Services Task Force (USPSTF) upcoming release of recommendations regarding prostate cancer screening and prostate-specific antigen (PSA) testing. Once again, millions of men and their loved ones are left to sort out the conflicting messages and try to make an informed decision regarding prostate cancer screening.

For more than two decades, annual PSA testing of men aged 50 or older in combination with digital rectal examination (DRE) has been the standard screening approach for the early detection of prostate cancer. It is the most common cancer diagnosis in men with an estimated 250,000 new cases in 2011. Despite the perception in the media that prostate cancer is not dangerous, it is the third leading cause of cancer death in men, causing more than 30,000 deaths annually. While many men may die of their prostate cancer, the majority of others will go on to live long lives and die of other causes--even if their prostate cancer is never treated.

Herein is the dilemma.

Prostate cancer has two faces: one a killer and the other a virtually harmless “disease,” that nevertheless affects patients with all of the anxiety that accompanies the diagnosis of “cancer.” PSA testing as a screening test fulfills its requirements, i.e. it is inexpensive, easy to perform (simple blood test), and most importantly, detects prostate cancer at an early stage when it is potentially curable. Full Post - to Detail View