Gentlemen of a certain age, take note: The dogma around prostate-cancer testing and treatment has changed markedly.
It's worth taking a minute to think about why, how and even if you should be tested. Further, if you do have a diagnosis of prostate cancer, you need to seriously consider whether or not you should actually be treated.
At first blush, those statements may seem like heresy.
But a landmark study, published in the New England Journal of Medicine, has provided some stark data on the benefits, risks and necessity of treatment for men with low- or medium-risk prostate cancer (meaning they have a Gleason score of 6-7).
The uplifting news is that, a decade after diagnosis, 99 per cent of men with early prostate cancer are still alive. The sort-of-surprising news is that mortality rates don't really vary depending on type of treatment, or whether a man is treated at all. "There's no hard evidence that treating early disease makes a difference," said Freddie Hamdy, a professor of surgery at the University of Oxford and the study's lead author.
Researchers examined data form 82,000 British men who underwent prostate-specific antigen (PSA) testing. Of that total, 2,700 were diagnosed with prostate cancer and 1,643 agreed to be assigned randomly to one of the three groups: prostate surgery, radiation treatment and active monitoring (meaning they were tested regularly to see if the cancer spread).
Of the 545 men in the active-monitoring group, 33 developed metastases (spread of cancer) and eight died; among those who had their prostate removed, there was 13 metastases and five deaths, and in the radiation group 16 and four respectively. In other words, doing 'nothing' (surveillance) resulted in a slightly higher risk of cancer spreading – 6 per cent vs. 3 per cent – but not a statistically significant increase in mortality, at least after 10 years.
But the catch is this: Those who underwent more aggressive treatment had a lot more side effects. For example, six months after diagnosis, 46 per cent of men who underwent prostate surgery were incontinent and using adult diapers, compared to 4 per cent in the active surveillance group.
Similarly, only 12 per cent of men who underwent surgery were able to sustain an erection, compared to 22 per cent in the radiotherapy group and 46 per cent in the active surveillance group. Half the men in the active-monitoring group eventually underwent surgery or radiation but, in the interim, they had better quality of life.
This sort of analysis is important because about 24,000 men are diagnosed with prostate cancer each year in Canada. While everyone wants to be cured, they do not always think of the price to be paid, like incontinence, impotence and depression. The good news is that, in Canada, active surveillance is already the norm for more than half of patients with localized prostate cancer. But, according to research by the Canadian Partnership Against Cancer, rates vary a lot around the country, so more work needs to be done.
The other element of this story, which is not part of the new research, is about the effectiveness and appropriateness of testing. Another study published recently showed that digital rectal examination is a poor way of detecting prostate cancer and shouldn't be done because it provides "maximal pain for minimal gain."
PSA testing, for its part, is one of the most controversial issues in the cancer field. It doesn't actually detect cancer, but elevated PSA levels trigger biopsies and often lead to a cascade of overtreatment. In Canada, routine PSA tests are not recommended.
What we really need is a test that shows if prostate cancer, once detected, will prove aggressive and deadly or not, and we don't have that. Prostate cancer kills 4,100 Canadian men a year, but it's not by doing more and earlier testing and more aggressive treatment that we will necessarily reduce that number. That's a hard message to digest, and deliver.
More than anything, the latest research provides a welcome reminder that, despite the fear the C-word strikes in our hearts, having a bit of cancer in your body is not necessarily an emergency. If you do get a prostate-cancer diagnosis, there is no rush to receive treatment and many reasons to ponder the pros and cons while continuing to live your life to the fullest.