Last summer, Joe Loree made an appointment to see his
urologist.
He’d occasionally noticed blood in his urine and wanted to
have that checked out. His doctor ordered a prostate-specific antigen, or PSA,
test to measure a protein in his blood that might indicate prostate cancer — or
a number of more benign conditions.
اضافة اعلان
“It came back somewhat elevated,” said Loree, 68, an
instructional designer who lives in Berkeley, California. A biopsy found a few
cancer cells, “a minuscule amount,” he recalled.
The c-wordLoree was at very low risk, but nobody likes hearing the
c-word. “It’s unsettling to think there’s cancer growing within me,” he said.
But because his brother and a friend had both been diagnosed
with prostate cancer and had undergone aggressive treatment, Loree felt
comfortable with a more conservative approach called active surveillance.
It typically means periodic PSA assessments and biopsies,
often with MRIs and other tests, to watch for signs that the cancer may be
progressing. His hasn’t, so now he can get PSA tests every six months instead
of every three.
Active surveillance
Research shows that a growing proportion of men with
low-risk prostate cancer are opting for active surveillance, as medical
guidelines now recommend.
The diagnosis used to lead directly to aggressive treatment.
As recently as 2010, about 90 percent of men with low-risk prostate cancer
underwent immediate surgery to remove the prostate gland (a prostatectomy) or
received radiation treatment, sometimes with hormone therapy.
But between 2014 and 2021, the proportion of men at low risk
of the cancer who chose active surveillance rose to nearly 60 percent from
about 27 percent, according to a study using data from the American Urological
Association’s national registry.
“Definitely progress but it’s still not where we need to
be,” said Dr Matthew Cooperberg, a urologic oncologist at the University of
California, San Francisco, and lead author of the study.
Approaches varyChanging medical practice often takes a frustratingly long
time. In the study, 40 percent of men with low-risk prostate cancer still had
invasive treatment. And approaches vary enormously between urology practices.
The proportion of men under active surveillance “ranges from
0 to 100 percent, depend on which urologist you happen to see,” Cooperberg
said. “Which is ridiculous.”
The latest results of a large British study, recently
published in the New England Journal of Medicine, provide additional support
for surveillance. Researchers followed more than 1,600 men with localized
prostate cancer who, from 1999 to 2009, received what they called active
monitoring, a prostatectomy or radiation with hormone therapy.
Over an exceptionally long follow-up averaging 15 years,
fewer than 3 percent of the men, whose average age at diagnosis was 62, had
died of prostate cancer. The differences between the three treatment groups
were not statistically significant.
Although the cancer in the surveillance group was more
likely to metastasize, it didn’t lead to higher mortality.
“The benefit of treatment in this population is just not
apparent,” said Dr Oliver Sartor, an oncologist at the Mayo Clinic who
specializes in prostate cancer and who wrote an editorial accompanying the
study.
“It doesn’t help people live longer,” Sartor said of the
treatment, probably because of what is known as competing mortality, the
likelihood of dying from something else first.
That’s why guidelines from the US Preventive Services Task
Force and the American College of Physicians recommend against routine prostate
cancer screening for men over 69 or 70, or for men who have less than a 10- to
15-year life expectancy. (Men ages 55 to 69 are advised to discuss the harms
and benefits with health care providers before deciding whether to be
screened.)
Newly revised guidelines from the American Urological
Association recommend shared decision-making after age 69, taking into account
age, life expectancy, other risk factors and patients’ preferences.
“If you live long enough, prostate cancer is almost a normal
feature of aging,” Cooperberg explained. “By the 70s or 80s, half of all men
have some cancer cells in their prostates.”
Most of those tumors are deemed “indolent,” meaning that
they don’t spread or cause bothersome symptoms.
Nevertheless, about half of men over 70 continue PSA
screening, according to a new study in JAMA Network Open. Though testing
declined with age, “they really shouldn’t be getting screened at this rate,”
said lead author Sandhya Kalavacherla, a medical student at the University of
California, San Diego.
Still getting routine PSA testsEven among men over 80, almost 40 percent were still getting
routine PSA tests. An elevated PSA reading can prompt a cascade of subsequent
tests and treatments, because “‘cancer’ is an emotionally charged term,” Sartor
acknowledged. He still sees patients, he said, whose response to very low-risk
cancer is, “I want it out, now.”
But treatment involves significant side effects, which often
ease after the first year or two but may persist or even intensify. The British
data showed, for instance, that six months after treatment, urinary leakage
requiring pads affected roughly half of the men who’d had a prostatectomy,
compared with 5% of those who underwent radiation and 4 percent of those under
active surveillance.
After six years, 17 percent of the prostatectomy group still
needed pads; among those under active surveillance, it was 8 percent, and 4
percent in the radiation group.
Similarly, men under active surveillance were more likely to
retain the ability to have erections, though all three groups reported
decreased sexual function with age. After 12 years, men in the radiation group
were twice as likely, at 12 percent, to report fecal leakage as men in the
other groups.
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