Screening for prostate cancer – an old argument revisited

Links to material quoted are given fully at the end of this post.

Gee! It's almost two years since your Grumpy Old Journo – also known as a Happy Prostate Cancer Survivor – put up some posts disagreeing with Simon Chapman, a strong opponent of screening for prostate cancer. On November 6, 2007, I said:

Gee! Me against the Professor of Public Health at the University of Sydney. This should be a one-sided debate. But here goes.

If you've dipped into this blog over the past year or so, you'll know I'm passionate in urging mature men to ask their doctor for a prostate cancer check.

And although I've read Professor Chapman's article in Monday's Sydney Morning Herald [November 5, 2007, headed “Prostate screening not worth it”] – and was already familiar with the arguments he has put – I will not change my advocacy.

I went on to explain:

The reason is simple. Early detection of prostate cancer, before any symptoms became apparent, may have saved my life. At the very least, it saved me from having to make decisions about more risky treatment of an aggressive cancer after it had spread further. I hope you'll bear with me.

I'm trying to explain that screening is worthwhile for most mature men, provided the guy (and his wife and friends) understand its limitations.

All treatment options – including non-treatment, ranging from "watchful waiting" to "no point
worrying about it at your age" – have risks and shortcomings. What's the right treatment for one guy might be ill-advised for the next.

So now, almost two years later, Professor Chapman, in an article jointly authored by a colleague, Associate Professor Alexandra Barratt, has returned to the SMH's pages to reiterate opposition to screening.

Under the heading, “Irresponsible prostate proposal ignores risk of harm to men”, the professors attacked last Wednesday's call by the Urological Society of Australia and New Zealand for men to have prostate cancer tests at age 40 instead of the previously recommended age of 50.

The professors' argument, basically, is that studies show screening fails to save many more lives despite higher costs to the public health budget. They ask:

What are the costs of close monitoring of half the nation's men aged in their 40s? What health-care services are going to be cut to cover the additional costs? Or must the health care budget be increased?

Cost-effectiveness? The Urological Society's recommendation means that men should ask their family doctor to order a blood test for PSA – prostate specific antigen – and to do a digital rectal examination at age 40.

Most guys should have a general medical check-up around that age, involving heart, blood pressure and blood testing of cholesterol, so why shouldn't they also ask for a prostate cancer check?

Apart from the pathologist's charge for the PSA test, where's the significant extra cost? And close monitoring? That will only happen if your doctor believes your PSA or DRE results are a cause for concern – and brother, if your doctor thinks that, won't you be glad you asked for the test?

“Risk of harm to men” are the words in the heading. This refers both to the risks involved in a biopsy, and to possible over-aggressive surgery or radiation treatment when cancer is found.

But my experience is that despite the risk of infection from a biopsy, it's worth that risk because it will allow your urologist to avoid aggressive treatment if it's not needed. For some men the biopsy may show there's no need to begin treatment, but to accept "watchful waiting" with PSA tests from time to time.

It would be unproductive to run a longer post arguing my position. The following links should help anyone seeking more understanding of the debate.

My November 2007 post outlined my arguments at length – indeed, it was so long I followed with an “executive summary”.

Last Wednesday, the Urological Society published its new policy here and also issued this media release.

The next day, professors Chapman and Barratt had their article published in the SMH. And here's Professor Chapman's SMH article published in November '07.

Last week, the SMH published letters contesting the professors' views on Friday (including a letter from Urological Society president Dr David Malouf denying the society advocated a screening program, instead saying it recommended 40-year-old men "should be offered a prostate cancer test to assess their risk") and another letter yesterday (on each of these letters pages you'll need to read down a way to find the relevant letters).

You'll also find a good explanation of prostate cancer and its treatment options in Wikipedia.

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Me and my prostate: An executive summary

Sometimes you can get too close to a topic. And that's what happened in my earlier post, the one which follows this.

I've been tossing around since the early hours wondering what to do about it. Surely it's too long? Does it say far more about my prostate than you really want to know? Is it boring?

And worse, does it fail to drive home arguments I believe to be important?

Yes, yes, yes and yes! Then, about 4am, the answer came to me. What I need is an executive summary.

So here's a first from Grumpy Old Journo. An executive summary:

• Professor Simon Chapman, and many other researchers, believe prostate cancer screening isn't worthwhile.
• The initial screening is unreliable. If abnormalities are found, the patient must have a biopsy to confirm diagnosis, and the biopsy procedure itself carries risks.
• Even if a man has prostate cancer, he's probably going to die of something else first. Many men have prostate cancer when they die, but they've never had symptoms and it's not what killed them.
• Treatment may end the patient's sex life and leave him wearing incontinence pads. Even if it does extend his life – and that's uncertain – his quality of life may be diminished.
• However, screening may become valuable if better screening tests can be developed.

Against that, I'd like to put a counter-argument based on my experience and my reading:

• Despite their shortcomings, screening tests can indicate prostate cancer.
• Follow-up biopsies do carry risks of infection and some pain, but they are valuable, not only in confirming a cancer diagnosis, but in calculating the aggressiveness of the cancer – is it likely to spread into lymph nodes and pelvic bones?
• With this information, a guy (and his wife) can make sensible decisions about treatment options, including the option of no treatment. All specialists will explain the pros and cons
  of treatment they suggest and will offer booklets which set out that advice.
• Professor Chapman's findings are based on statistical analysis of thousands of men. With sound evidence, good advice and sensible decisions, a guy could beat the odds.
• Screening is the first step on the path which may lead you to a better outcome.

Jesus wasn't talking about the prostate health of his listeners, of course, but you might find his words of value when you think about screening:

"You shall know the truth, and the truth will set you free" [John 8:32]

I've got the following links at the end of the next post, but to save your time, here they are again: Professor Chapman's article in the Sydney Morning Herald, and a long, detailed Wikipedia entry.

To screen or not to screen – a question for the mature male

Gee! Me against the Professor of Public Health at the University of Sydney. This should be a one-sided debate.

But here goes. If you've dipped into this blogsite over the past year or so, you'll know I'm passionate in urging mature men to ask their doctor for a prostate cancer check. And although I've read Professor Chapman's article in Monday's Sydney Morning Herald – and was already familiar with the arguments he has put – I will not change my advocacy.

The reason is simple. Early detection of prostate cancer, before any symptoms became apparent, may have saved my life. At the very least, it saved me from having to make decisions about more risky treatment of an aggressive cancer after it had spread further.

I hope you'll bear with me. I'm trying to explain that screening is worthwhile for most mature men, provided the guy (and his wife and friends) understand its limitations.

All treatment options – including non-treatment, ranging from "watchful waiting" to "no point worrying about it at your age" – have risks and shortcomings. What's the right treatment for one guy might be ill-advised for the next.

As I've previously recorded, my wife Merry persuaded me to ask my GP for a prostate check (I've read that 80 per cent of men who do ask are yielding to their wives' nagging).

The GP ordered a blood test for PSA – prostate-specific antigen – which came back a bit high. A digital rectal examination did not reveal any abnormalities, but then, not all prostate cancer can be detected with a probing finger.

So first the doctor treated me with antibiotics. Perhaps I had a simple infection, or perhaps non-cancerous benign prostatic hyperplasia.

The PSA continued to rise, so it was off to see a specialist urologist. After more examination, he performed a biopsy.

The results came back – no cancer had been detected. Merry and I enjoyed a good bottle of wine that night.

But follow-up tests showed an alarming leap in my PSA reading, and the urologist recommended another biopsy. If I remember right (I was zonked out with valium at the time), he told me he had taken 18 tissue samples, and the pathologist detected cancerous cells in just one.

However, the pathologist gave the cancer a Gleason score of seven. Gleason scores rank the cancer's aggressiveness from a relatively benign two to an alarming ten, and seven is at the aggressive end.

There is another vital score called staging – usually T1 through to T4, based on how far the cancer has spread. For me, there wasn't enough information to rank my cancer on what basically is a description.

The urologist referred me to a radiation oncologist, who felt the cancer had already spread into my pelvic lymph nodes. (I know a little about lymph nodes because a surgeon had to remove those under my left arm after melanoma spread its cells – but that was more than 30 years ago.)

After ultrasound and other imaging confirmed his opinion, we agreed radiation treatment would be appropriate. First, however, the radiation oncologist put me on a course of Androcur to stop my body's production of testosterone.

The aim was to starve and shrink the cancer to make it a better target for radiation. But the drug achieved a much better result. PSA tests, imaging and digital examination all indicated the cancer had disappeared or was now insignificant.

It may come back, of course, either as a new cancer or as a flare-up of a few cells which linger. Time will tell, but for now, and until I'm too old for it to matter, I'm happy to accept "watchful waiting" as my treatment option.

The experience of just one guy – me – doesn't have much statistical significance when ranged against studies by medical and academic experts published in peer-reviewed journals. But it still matters to me, and I think it will help me make some worthwhile points.

First, on screening itself: Understand what it can do, and what it can't. Initial screening may give false assurance that the guy does not have prostate cancer. But a good doctor today will use both PSA blood tests and a finger examination, although each technique is imperfect, and perhaps the doctor will also monitor changes over time.

If those techniques lead to concern that cancer may be present in the prostate, it's time to see the urologist. Again, your family doctor – assuming you have one, and don't attend a medical centre where you're just a name on a computer – will be invaluable, suggesting specialists who are not only well regarded for their expertise, but who are also able to explain the diagnosis and treatment options to patients and wives who may be shocked and uncomprehending.

Only one diagnostic tool can reliably confirm prostate cancer and measure its aggressiveness – a biopsy.

But even a biopsy is not risk-free. Apart from the possibility of a false negative result such as I received, it also carries a risk of infection. To collect the tissue samples, a fine, hollow needle has to go through the rectum and into the prostate itself. The urologist will have prescribed strong antibiotics to suppress infection, and something like valium to calm the patient, but things can go wrong.

After all this, however, you should know whether your prostate has cancer, how aggressive it is, and perhaps whether it's metastasising, scattering malignant cells to grow in your lymph nodes or in adjacent bones.

All that's worth knowing, because it helps you make sensible decisions about what to do next.

Indeed, it's vital to know about the full range of treatments you may be offered. How effective they may be, how significant are the risks, or even whether it would be better to have no treatment at all.

Close to the prostate are nerves which control erection, bladder and anal functions, and radiation or surgical treatment may damage them. Some treatments make such damage probable, not just possible.

Let's say you're about 60, healthy and active and enjoying good sex, and your prostate cancer is relatively low on the Gleason scale. Almost certainly, your wisest move is to do nothing, but let your doctors check from time to time – "watchful waiting".

On the other hand, let's say you're over 80 and on to your second pacemaker. Treatment for prostate cancer probably won't prolong your life – you'll die first of something else – but it's likely to diminish the quality of your remaining years. Screening? Why bother?

But between those extremes, what about guys like me? Late 60s, aggressive cancer already metastasising. I'm in reasonable health, and that cancer threatened to shorten my life and perhaps end it with pain. I'm satisfied screening and then treatment was my best option.

However, Professor Chapman's views have strong support. Here's how Wikipedia reports on the issue (there's a link at the end of this post):

Screening for prostate cancer is controversial because it is not clear if the benefits of screening outweigh the risks of follow-up diagnostic tests and cancer treatments.

Prostate cancer is a slow-growing cancer, very common among older men. In fact, most prostate cancers never grow to the point where they cause symptoms, and most men with prostate cancer die of other causes before prostate cancer has an impact on their lives.

The PSA screening test may detect these small cancers that would never become life threatening. Doing the PSA test in these men may lead to over-diagnosis, including additional testing and treatment. Follow-up tests, such as prostate biopsy, may cause pain, bleeding and infection.

Prostate cancer treatments may cause urinary incontinence and erectile dysfunction.

Therefore, it is essential that the risks and benefits of diagnostic procedures and treatment be carefully considered before PSA screening.

And let's note the final words of Professor Chapman's article:

What is urgently needed is a diagnostic test that will accurately predict those prostate cancers which will turn nasty. The tests we have now have poor reliability in that regard. Research funding into the development of such tests is vitally important.

Forgive me for talking so much about my prostate. I know this post is long, and that I have a tendency to preach. But despite the flaws in prostate cancer diagnosis, I still believe screening is valuable for detecting cases such as mine. To get the full benefit, however, a guy needs to understand much more about the diagnostic tools and also the pros and cons of treatment options.

The Wikipedia entry quoted above offers an excellent explanation of prostate cancer and the issues of diagnosis and treatment. And you can read Professor Chapman's article here.

A test in the nick of time

You don't usually thank your wife for nagging, but this year I'll make an exception. Merry saved my life when she kept at me to go for a prostate test.

Early results were inconclusive. I had a worryingly high level of PSA (prostate specific antigen) in the blood. Nobody could find a trace of a tumour, and I had no symptoms, so I was treated with antibiotics to get rid of possible infection.

The PSA stayed high, so my doctor sent me to a urologist. More tests, then a biopsy where he took lots of samples. They all came back clear, and Merry and I celebrated with a good wine.

But a couple of months later, a rise in the PSA reading to 95 set off another alarm, so it was back for another biopsy. This time a pathologist found one tiny tumour in one of the 18 samples taken by the urologist.

The bad news was that pathology showed the cancer was aggressive, and the rapid rise in PSA suggested a bigger tumour somewhere, perhaps hidden between the prostate and the bladder.

Next referral was to a radiation oncologist. His examination indicated swelling in the pelvic lymph nodes. Had the tumour already begun to metastasise, spreading into other parts of the pelvis? It seemed likely.

Then came almost miraculous news. I'd been put on a course of Androcur, a drug which stops the body producing testosterone. The aim was to shrivel the tumours so they'd be better targets for radiation treatment.

But the drug worked far better than that. My PSA plummeted from 96 to 2.4 – that's two-point-four – and imaging showed the tumours had shrunk so much they were almost indiscernable. It's likely I won't need radiation, and Androcur may keep the cancer suppressed for years to come. I'll know more when I'm next tested in February.

There is, of course, the obvious side-effect. And now, of course, I'm noticing the world is full of women with warm smiles and inviting eyes. Sigh.

The point of this post, apart from letting friends know how I'm going, is to note that in some cases, such as mine, there's only a small window of time between the earliest that detection is possible and the latest when treatment will be effective. A checkup by a doctor, who will continue to monitor any PSA abnormality, is good sense.

Merry's nagging meant my cancer was discovered within that window. Thanks, love.

And fellas, “be a man”. Don't worry about the doctor's finger. Actually, I found the procedure excruciating – not the finger, but the dreadful jokes my GP told to take my mind off what was going on.