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 The finding points to the success of efforts to curtail the use of
controversial prostate-specific antigen, or PSA, screening tests,
said lead author Dr. Tudor Borza.
At the same time, his team found, doctors still face challenges
trying to convince men diagnosed with early-stage prostate cancer to
watch and wait before undergoing surgery or other invasive
treatment, Borza said.
From 2007 to 2012, Medicare data showed a relatively meager 8
percent drop in the number of men who were treated immediately after
a prostate cancer diagnosis, Borza’s team reports in Health Affairs.
Borza, a urologist and research fellow at the University of Michigan
Health System in Ann Arbor, said he feared the statistics might mean
that too few men are being screened, and among those who do get a
prostate cancer diagnosis, too few are following the strategy of
watchful waiting and surveillance recommended by urologists for
early-stage tumors.
“I believe more men should be screened,” Borza said in a phone
interview. “A diagnosis of prostate cancer shouldn’t necessarily
lead to treatment.”
A PSA test measures the amount of a protein known as
prostate-specific antigen in a man’s blood. Often, however, the test
falsely signals possible cancer, causing anxiety and leading to
unnecessary, invasive and sometimes debilitating procedures.
Moreover, many men are likely to die of other causes before
slow-growing prostate cancer harms them. But once they’ve been
diagnosed with prostate cancer, men frequently elect to be treated
and can suffer punishing side effects, including impotence and
incontinence.
“Diagnosis has a way of begetting treatment, whether or not it
warrants treatment,” said Dr. Gilbert Welch, professor of medicine
at the Dartmouth Institute for Health Policy and Clinical Practice
in Lebanon, New Hampshire. He was not involved with the new study.
“Patients think once cancer is there, you’ve got to act,” Welch said
in a phone interview. “The question is whether you want to be
looking for early forms of cancer.”
Borza and Welch both believe the decision should be left to
individual men. But the two physicians approach the question from
differing perspectives. Borza’s interest in continuing to screen men
for prostate cancer with PSA tests generally aligns with other
urologists, and Welch’s preference for less screening aligns with
other primary-care physicians.
In 2008, the U.S. Preventive Services Task Force (USPSTF) advised
against routine PSA testing of men older than 75. By 2011, the
government-backed panel of independent physicians recommended
against all PSA screening, warning that the benefits do not outweigh
the harms.
The American Urological Association, however, recommends that men
weigh the benefits and harms of PSA screening in conversations with
their doctors and finds the greatest value to screening in 55 to 69
year olds.
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Borza and his team analyzed Medicare data and identified more than
67,000 men age 66 and older who were diagnosed with prostate cancer
between 2007 and 2012. During the same period, the population-based
rate for men treated for prostate cancer dropped 42 percent, from
4.3 per 100,000 men to 2.5 per 100,000, the study shows.
Nearly three-quarters of the men diagnosed with prostate cancer had
curative treatment, such as surgery or radiation, within a year,
while 17 percent instead opted for “watchful waiting” or “active
surveillance,” the study found.
Most of the men diagnosed with prostate cancer were between 66 and
75 years old, but nearly 16 percent were 80 and older - too old to
likely benefit from treatment, according to the USPSTF guidelines.
Men are much more likely to die with prostate cancer than from it,
Welch said.
“The question is whether you want to be looking for early forms of
cancer,” he said. “There’s no limit to how much data we can collect,
but that doesn’t mean we want all that information. It can lead
people down a rabbit hole.”
Borza sees it differently.
“Information is power,” he said. “Knowing where you stand allows you
to make the best decisions.”
Nonetheless, he acknowledges that deciding whether and how to treat
an early-stage prostate cancer diagnosed after a PSA test can be an
agonizing decision. And no one can say how many lives might be saved
by treating those cancers.
Borza recommends men consider getting PSA tests at 50 years old.
But, he said, “It is a very difficult decision for a man to make.
There’s not a great answer.”
SOURCE: http://bit.ly/2hww6B9 Health Affairs, online January 9,
2017.
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