There's a popular saying: men are more likely to die with prostate cancer than from it.
But it's a loaded statement with which many don't agree. The result is a debate – a very heated one – over the best way to screen for prostate cancer, and once it's found, whether to treat it aggressively with surgery or radiation, or leave it alone.
On one side of the screening debate are experts who argue the prostate-specific antigen (PSA) test, long the most common test used to look for suspected cancer, is one of the best ways to catch the disease early and help men get successful treatment.
On the other side are those who suggest the usefulness of the PSA test is wildly overblown, considering it leads to false positives, overdiagnosis and overtreatment of a disease that, if left alone and monitored closely, would never pose a real health threat to many men.
A new study published Tuesday in the New England Journal of Medicine set out to answer the question of what happens to men in the long term after a PSA test finds prostate cancer. So while the study didn't directly address the questions around the benefits and harms of PSA screening, it showed that, overall, the survival rate among men with prostate cancer is very, very high. This adds to the growing evidence that doing less is just as good, if not better, than being aggressive with the disease.
The Canadian Cancer Society estimates suggest that 24,000 men were diagnosed with prostate cancer in 2015, while 4,100 died from the disease – about 10 per cent of all cancer deaths among men. Men with the disease are 96 per cent as likely to survive five years after diagnosis as the general population, according to the society.
There's no simple test that can tell when a man has a case of prostate cancer that needs to be treated. Instead, doctors have long relied on the PSA test, which looks for elevated levels of the prostate-specific antigen test in the blood, which can signal the presence of cancer. For years, men were told to get regular PSA tests starting at age 40 or 50, depending on their particular risk factors.
But here's the wrinkle: many men can have elevated PSA levels without the disease. In fact, experts suggest that only one in four men with elevated PSA levels have prostate cancer. So that means many men with elevated levels would undergo biopsies and other forms of unnecessary follow-up.
Since prostate cancer is also a slow-growing disease, many doctors say too many men in early stages of the disease undergo aggressive treatment, even though there's a strong likelihood the cancer would have never progressed to the point of being a serious health risk.
That might not be a problem, except that follow-up and treatment leads to a host of side effects: anxiety, fatigue, incontinence and sexual dysfunction, to name a few.
Recognizing these problems, the Canadian Task Force on Preventive Health Care published new screening guidelines in 2014 to provide doctors with some clarity. The guidelines recommended against PSA testing for men who had never been diagnosed with the disease because the benefits are too small and the risk of harm is too great. The guidelines are in line with ones published by the U.S. Preventive Services Task Force a few years earlier.
Urologists and prostate cancer advocacy groups have loudly criticized those recommendations since they were published. Groups such as Prostate Cancer Canada continue to promote the benefits of PSA testing and have created a website and social-media campaign to encourage men to get tested.
Forget the conflicting opinions. What does the evidence actually say? The New England Journal of Medicine Study provides some important insight. The study was large: Of the more than 82,000 men in the United Kingdom age 50 to 69 who had a PSA test from 1999 to 2009, nearly 2,700 received a cancer diagnosis. Of those, 1,643 agreed to be randomized into one of three treatment groups: radiation, radical prostatectomy, or removal of the prostate gland, or active surveillance, which involved redoing PSA tests to monitor for changes.
The point of the study was to see what mortality rates looked like years later. After a decade, the results were in: about 99 per cent of the men survived, regardless of which group they were in. The men who underwent active surveillance were just as likely to survive as those who had a radical prostatectomy.
The study found disease progression, including metastases, or cancer that has spread to other parts of the body, in 204 men. Progression was more common in the active surveillance group (112 versus 46 in the surgery group and 46 in the radiation group). Several men had complications as a result of treatment, including heart problems, need for blood transfusions and one reported rectal injury.
According to the authors, 27 men would have to have prostate removal surgery to prevent one man from developing metastatic disease, while 33 men would have to undergo radiation to avoid one case of metastatic prostate cancer.
What men need to know
How you interpret the results may depend on your particular point of view. Stuart Edmonds, vice-president of research, health promotion and survivorship at Prostate Cancer Canada, said the results likely won't change anything because the follow-up period was too short. You would need to follow men for a longer period of time to truly capture what impact various courses of treatment have on mortality rates, Dr. Edmonds said. He added that more doctors in Canada are advocating for active surveillance to help reduce the risk of overtreatment.
In an e-mail, Neil Bell, one of the authors of the 2014 Canadian guidelines, pointed out that deaths and the rate of disease progression were low among all study participants. He added an important point – that the study didn't shed light on rate of incontinence, erectile dysfunction and other side effects experienced by the men in the surgery and radiation groups. According to Dr. Bell, men "still need to consider the balance between harms and benefits" related to screening.
And while active surveillance might sound like a happy medium, some experts say it is often unnecessary and can lead to unnecessary anxiety and follow-up tests.
It doesn't appear likely the prostate cancer screening debate will end any time soon, which can lead to plenty of confusion and uncertainty among men faced with the decision about whether or not to get a PSA test.
The Canadian Cancer Society has some good advice to follow in the meantime: before making a choice, ask your doctor about whether or not you have prostate cancer risk factors, whether you would benefit from screening and what would happen if the results are normal – and what course of action would unfold if they come back elevated.