Study indicates screening for prostate cancer may not be helpful

McClatchy Newspapers (MCT) - Despite two large studies released Wednesday, uncertainty lingers for men weighing whether to be tested or treated for prostate cancer.

For every life saved, dozens of men undergo potentially damaging treatment _ including some men who never would have died of cancer.

"PSA (screening tests) and the fear of prostate cancer are absolutely ingrained in most Western societies right now," Dr. Gerald Andriole, one of the study authors, said in a telephone news conference. That makes it critical for doctors to temper knee-jerk responses to a positive test, he said.

Men diagnosed with prostate cancer face two stark quandaries.

First, doctors cannot tell whose tumors will grow slowly for decades, as the men age and eventually die of something else, and whose tumors will spread swiftly and lethally.

Second, if men opt for treatment to be on the safe side, their choices are bleak. Prostate surgery often causes impotence, at rates ranging from 40 percent to 75 percent, and also can cause incontinence. Radiation, too, can cause impotence and urinary and rectal problems _ all side effects that can trigger deep depression.

With treatment potentially so damaging, the big question for researchers is whether a PSA screening, which starts the diagnosis ball rolling, does more harm than good.

"There is a legitimate question as to whether we should be screening," said Dr. Otis Brawley, chief medical officer of the American Cancer Society.

The screening itself is a blood test that measures levels of a protein called prostate specific antigen. PSA levels can be elevated in men with prostate cancer but also with other conditions that are more common as men age. Once an elevated PSA is found, a biopsy can determine if cancer is present, and then men face the harrowing treatment choices.

"Everyone has been eagerly awaiting the results" of the major U.S. study, said Dr. Vijay Suhag, an oncologist who works at Sutter Auburn Faith Hospital. "This is a major, major effort on the part of the National Cancer Institute to kind of clarify some of these issues."

Yet with the interim results being published later this month in the New England Journal of Medicine, "the jury is still out," Suhag said.

The NCI study of nearly 80,000 American men concluded that PSA screenings do not save lives, at least in the first seven to 10 years afterward. There was no statistically significant difference in death rates between groups of men who were screened at fairly high rates and groups that got much less screening.

That study will appear side by side in the medical journal with European research that concluded PSA screenings cut death rates by 20 percent. It involved more than 160,000 men followed for up to 15 years.

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The European study noted, though, that to save one life, 1,400 men had to be screened and 48 had to undergo treatments that can lead to impotence, urinary problems and other complications.

"When I'm talking to a man, I have to admit there probably is a small advantage to screening but ... that test is 47 times more likely to harm him than to save his life," said the American Cancer Society's Brawley.

A tiny minority of men die of complications of prostate cancer surgery. Of those who survive, he said, some have their worst struggles with incontinence.

"Many of these guys wear two or three diapers per day," Brawley said. "It is devastating emotionally."

Because of differences in study designs, several doctors said that the European and American research efforts complement each other more than they conflict.

Given more years of follow-up, they suggested, the U.S. research might also show a modest life-saving benefit for prostate cancer screening _ or the European results could fall below statistical significance.

Today, medical authorities disagree on who should be tested for prostate cancer.

The U.S. Preventive Services Task Force says there's not enough evidence to know whether PSA screening does more harm than good for men younger than 75. Above that age, it recommends against screening.

The American Cancer Society suggests that PSA tests be discussed with men who have normal cancer risk once they turn 50.

"Unquestionably, some people are going to be treated who would have been fine if they were not treated," said Dr. Ralph deVere White, director of the UC Davis Cancer Center.

Even so, "we believe that PSA saves lives," he said.

Nearly 30,000 American men annually die of prostate cancer, one of the most common cancers. If more screening could reduce that by 20 percent, 6,000 men would be spared every year, he said.

Prostate cancer death rates have been declining in the United States since around the time PSA testing began. Doctors aren't sure how much of that is due to better treatment and how much to earlier diagnoses made possible by PSA screening.

In an effort to answer that question, the U.S. study will continue to monitor men who were screened years ago. Meanwhile, decisions about testing and treatment will remain an individual choice.

Paul Haley of Lincoln, Calif., who has been treated for prostate cancer, said when his friends ask him for advice, he urges them to be tested _ but then be ready to fight for whatever level of care they think is best.

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Haley said he had to push his doctor to get a then-novel treatment, which involved implanting radioactive seeds to combat his cancer.

For his 80-year-old father-in-law, Haley is urging a less proactive approach. He wants him to stop getting screenings.

"It's torturing him. He frets over it," said Haley, because his PSA is going up _ something often not dangerous in men his father-in-law's age.

Gary Little of Jackson, Calif., said some men in his prostate cancer support group have chosen "watchful waiting," declining invasive treatments in hopes that their cancer will grow so slowly that it won't kill them.

"Everybody has to make their own choice," said Little, but that wasn't his. He chose a radical prostatectomy to remove all cancerous tissue.

"Get it out of there, and then you can have a life," said Little, who has not suffered serious side effects from the surgery.

UC Davis' deVere White said he likes to talk to men with elevated PSAs before they have a biopsy, asking them to think about what treatment choices they might make.

When there is only a small amount of cancer, with cell patterns that indicate lower severity, "active surveillance is a totally, utterly good way to go" for some men, the doctor said. Others simply want the cancer out.

He urges patients to imagine each choice going wrong, and then asks, "If the outcome isn't perfect, which is going to leave you personally with the most regrets?"

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© 2009, The Sacramento Bee (Sacramento, Calif.).