Biopsy, Biopsy Everywhere

BY MARK SCHOLZ

A month ago I promised to expound more concerning our national passion for prostate biopsy. A million men are biopsied every year. Two hundred thousand will be diagnosed, the majority with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, most will undergo prompt radical treatment. Irrational fears drive most men into taking immediate action.

Since diagnosis overwhelmingly portends overtreatment, some experts have suggested that we put a stop to PSA testing. Practically speaking this will never happen. Patients and doctors alike are unwilling to forgo the information that PSA provides, imperfect as it may be.

  

Realistically speaking, PSA testing per se is not the real problem.  The problem is doctors and patients overreacting to the information PSA supplies. The solution is not less frequent PSA testing, but rather convincing physicians to slow down the rush to immediately biopsy men with slight PSA increases. Diagnosing every single case of prostate cancer is of highly questionable value. Many men would rather be spared the unnecessary knowledge that they have a non-threatening Low-Risk prostate cancer.

Rushing into an immediate biopsy only makes sense when aggressive cancer is present and that is much less common.

So where is the middle ground between immediate biopsy of every PSA elevation and forgoing PSA testing and biopsy altogether?

Before deciding to do a biopsy, the prostate gland should be measured with an ultrasound scan to determine whether it is abnormally enlarged.  If the amount of PSA elevation is proportionate to the degree of prostate enlargement, then the PSA elevation is due to benign cause. Rather than proceeding with an immediate biopsy, additional PSA monitoring and a urine test called PCA-3 may be helpful. 

PCA-3 is a relatively new test that measures ribonucleic acid (RNA) secreted by the cancer cells into the urine following manual massage of the prostate. Studies show that the amount of PCA-3 in the urine increases in proportion to both the size and aggressiveness of a man’s prostate cancer. Unlike PSA, PCA-3 is unaffected by the size of the prostate. Low amounts of PCA-3 in the urine, say less than 40, indicate that the presence of an underlying aggressive cancer is less likely.

If the PCA-3 and PSA density are favorable, further monitoring with some form of imaging offers additional insurance against missing the diagnosis of aggressive cancer.  Modern 3-Tesla endorectal MRI and high-resolution color Doppler ultrasound, while not perfect, are reasonably accurate methods for detecting aggressive cancers. 

So in summary, biopsy should be reserved for men with elevated PSA levels that can’t be explained by a prostate infection, laboratory error or recent sexual activity. Here are some signs that a biopsy may be needed:

1.                  A PSA elevation out of proportion to the size of their gland or

2.                  Abnormally elevated PCA-3 levels or

3.                  An abnormality felt on digital rectal examination or

4.                  Imaging studies suggestive of underlying aggressive cancer.

PSA is a remarkable tool that has transformed the management of prostate cancer over the last 20 years. Rather than triggering an immediate biopsy, an elevated PSA should lead to further investigation. Rushing to a biopsy simply because PSA is elevated frequently leads to unnecessary radical treatment with detrimental lifelong consequences.

Over-Diagnosis and Over-Treatment in the Flourishing Prostate Cancer Business

BY RALPH BLUM

There are several reasons why over-treatment of prostate cancer is rampant in this country. The first is over-diagnosis. In 2011, despite the controversy about annual PSA testing, more than 240,000 men were diagnosed with prostate cancer. Many of these men were in their 70s and 80s; most of them with disease that would never be clinically significant in their lifetimes. But a diagnosis of prostate cancer put them at immediate risk for unnecessary treatment. Why? Because both doctors and patients over-react to the information PSA testing provides.

The responsible urologist is faced with a dilemma: the risk of over-treatment versus the risk of his patient dying from prostate cancer. As of this writing there is still no absolute certainty, when a man is first diagnosed, about how to accurately differentiate between clinically significant and clinically insignificant prostate cancer.

Then there is the financial aspect: prostate cancer treatment and management has become a flourishing industry. Studies have found that three-quarters of men with indolent, slow-growing tumors receive unnecessary aggressive treatment, when active surveillance would be far more appropriate.

According to researcher Janet Stanford at the Fred Hutchinson Cancer Research Center, between $2 and $3 billion is spent annually in the U.S. on initial therapy alone. Urology groups that have brought IMRT into their practices have utilization rates well above national norms for treatment of prostate cancer, and these practices also treat a higher than average number of men over the age of 80 with IMRT for their low-risk cancer. Furthermore, with the soaring popularity of the da Vinci robot and the enormous costs of acquiring one, not to mention being trained in robotic surgery, there is a very strong incentive for urologists to recommend its use.

I’m not suggesting that men are not willing partner’s in this rush to treatment. Most men, confronted with a choice of monitoring their prostate cancer—as opposed to “cutting it out” or zapping it with radiation—will unequivocally choose the latter, even knowing that it is likely to lead to reduced quality of life. One of the results? Over 70,000 unnecessary prostate surgeries annually—and rising.

While PSA screening isn’t a perfect method of detection, catching prostate cancer early has saved many men’s lives. Over the last 30 years there has been a 30% decline in the death rate from prostate cancer due, in part, to better screening. However, all you guys out there who are diagnosed in your 70s or 80s, be aware that the highest incidence of over-treatment is in your age group—as high as 60-65% and possibly higher.  So take your time, and carefully examine your options!

As the prostate cancer wars rage on, all newly diagnosed men are faced with prostate cancer’s version of the Hamlet dilemma (“To be or not to be…”). As Leonard L. Gunderson, M.D, M.S, FASTRO and ASTRO Chairman put it, “The problem with prostate cancer is not finding the cancer but in knowing when to treat and when not to treat.”

The More Things Change the More They … Stay the Same

BY MARK SCHOLZ

Everyone knows there is overuse of surgery and radiation in the United States for men with Low-Risk prostate cancer. But do not assume increased awareness means things are getting better.  Actually, they are getting worse. 

A study in the February issue of this year’s Archives of Internal Medicine reports that in 1999, 38% of men with Low-Risk prostate cancer received unnecessary treatment.  By 2007 that percentage was up to 52%.  Another study published in this year’s February issue of the Journal of General Internal Medicine reports that one-third of men queried after radical prostatectomy could not even remember being offered any other option than surgery.

Monitoring rather than treating Low-Risk prostate cancer became a mainstream approach in 2007, when Dr. Peter Carroll at University of California at San Francisco convened a conference of more than 200 experts who unanimously validated active surveillance for men with Low-Risk prostate cancer.

So what was the result?

Over the next year, surgery increased 10% from 80,000 annually in 2007 up to 88,000 in 2008 (New England Journal of Medicine, August 2010).

How can this be? Don’t doctors put their patient’s best interests first? 

The average patient fails to realize that surgeons are a unique sub-classification of doctors.  If an average doctor is likened to army infantry, then surgeons are the Navy Seals. Highly-trained, talented and very mission orientated. (For more insight on Navy Seals, check out Act of Valor which is playing in theatres now.)

Surgeons experience the satisfaction of eradicating disease by cutting it out. However, they don’t come by this privilege without intense training involving great personal sacrifice.  Once they get their wings, they are part of an elite fraternity that rightly or wrongly considers itself the best of the best. Who is to tell them otherwise?

These surgeons, known in the prostate world as urologists, stand at the entry hall welcoming the 200,000 newly-diagnosed men every year who have a positive biopsy. Urologists do all the biopsies. Cutting the disease out is at its core exactly what the whole life of a urologist is about.  As the old saying goes, when you’re a hammer, everything looks like a nail.

If urologists won’t spread the word about active surveillance then who will?

There is no easy answer because men with newly-diagnosed cancer are frightened.  Naturally, they want a quick fix.  The option of surgery, enticingly presented by the urologist, fits that bill.

The best hope for change lies in the more than two million prostate cancer survivors.  Entreaties from close friends or families can slow the charge to surgery.  Most men, if given time to really examine their options, discover that other treatment options including monitoring leads to better results than surgery.

 

My personal frustration regarding this over-treatment motivated me, a journalistic amateur, to sit down and write a book. “Invasion of the Prostate Snatchers” is designed to give prostate cancer survivors a tool they can give their friends and family to explain why active surveillance is safe and to help open the eyes of men who wrongly think that prostate cancer is a death sentence.

The Legacy of the Saber Tooth Tiger: A Few Unkind Words About Stress

BY RALPH BLUM

Whatever the problem—heart, cancer, diabetes—stress is arguably Public Enemy #1 for half of what ails this nation. And when it comes to immune system health, stress rings cash registers. Advertising budgets dedicated to pushing the stress button are worth what Ted Turner would call “serious cash money.” The root briar of an estimated 20 billion dollar a year volume of advertising, stress is Big Business.

It is now more or less common knowledge that the most potent immune system suppressor is stress. Especially chronic stress—the kind suffered by all of us from the moment are diagnosed with prostate cancer. So manufacturers of specialty foods, supplements, herbs and minerals are climbing onto the bandwagon and claiming that their products are “immune system boosters.” However, if you look carefully you will see that 90% of their claims are laced with hedge-your-bet qualifying terms like “might,” “perhaps,” “could” and “can sometimes.” This is the stuff that scams are made of these days.

So when you don’t know whether your job is being abolished, and you are seeing your savings dwindle to nothing, and your anxiety over your children’s future is keeping you awake at night, and then, on top of all that, you are diagnosed with prostate cancer, how can you hope to cope with this kind of chronic stress barrage? What can you do that will genuinely assist your immune system to function efficiently?

The three tried and true stress busters are simple enough. They are diet, exercise, and meditation. You don’t have to pump iron or run marathons, or subsist on tofu, berries, and leafy greens. But in order to fight cancer successfully, you do need to eat a healthy diet and find a type of exercise you enjoy. And, at least as important, you need to find some kind of meditation that you can live with—it can be as little as fifteen minutes a day!—because it does reduce the stress that inevitably ramps up with a cancer diagnosis.

If you’re interested, you might check into the fairly new field of Psychoneuroimmunology. You’ll learn about the legacy of the saber tooth tiger, and how to distinguish the activity of the adrenal system from that of the immune system. Because there are two distinct conditions: there’s growth and there’s protection, but you can’t have both at the same time. And when any threat mobilizes the body with the old “fight or flight” response, the adrenal (stress) hormones directly repress the action of the immune system. Result: almost every major illness has been linked to chronic stress.

It is now fairly well established that what goes on in our minds absolutely affects our bodies.  There is no question that our thoughts and our beliefs generate a cascade of chemicals that can act to either harm us or heal us. So my best recommendation to you is to believe wholeheartedly that whatever treatment you decide on will be totally successful. And when the stress gets to you, you don’t have to sit crossed-legged on the floor and repeat a mantra provided by a guru in the Himalayas. Just turn on some relaxing music, breathe slowly and deeply, and imagine yourself walking on a beach, or in a forest—whatever works for you—and see yourself relaxed and healthy. Relieving the chronic stress of living with prostate cancer is arguably taking a long step on the road to recovery.