To treat or not to treat prostate cancer

Autopsy studies show that 50% of men over age 59 have prostate malignancy, and three out of four over age 85. One in seven North Americans will also be diagnosed with prostate cancer in their lifetime. Yet only one in every 28 men will die of prostate cancer! Obviously, not all men need to be treated.

A report in Nutrition Action says that most prostate cancers are harmless and before the PSA test became available, men never knew the disease was present. And Dr. Lawrence Klotz, chief of Sunnybrook Cancer Centre in Toronto, is concerned that unnecessary surgery or radiation treatment leaves some men with impotence, diarrhea and urinary incontinence.

Because of these complications, in 2012 the U.S. Preventive Service Task Force recommended that, because the harm exceeds benefit, men should not take the PSA test. The inventor of the test came to the same conclusion!

The problem is that some prostate malignancies are ‘pussy cat’ cellular changes, similar to gray hair, while others are like hungry tigers that kill. Now, more urologists, particularly in Canada, are saying there’s no hurry to rush treatment. Rather, it’s prudent to keep watch on low risk cancers using the PSA test, biopsies and the Gleason Score to separate low threat cancers from lethal ones.

The Gleason Score is determined by microscopic examination of a biopsy of the prostate gland. A pathologist analyzes the cellular pattern and gives a Gleason Score of 1 to 10. Dr Klotz informs patients with a Gleason 3 score that they have a pseudo cancer, part of the aging process. For those with a Gleason 6, Klotz says this is not a metastatic condition. And he believes that in older patients a Gleason 7 can be treated with surveillance. Even without treatment these patients live 15 or more years.

Klotz adds that since 1995 he has followed 1,000 Canadian men with localized prostate cancers using a PSA test every three to six months and a biopsy every six to 12 months. He has seen only 14 deaths due to prostate cancer and overall there was a 10 times greater chance of dying of causes other than prostate cancer.

Today a few cancer centers use an MRI to follow low-risk prostate cancers. But, whatever approach is used, there are no guarantees. For instance, a prostate biopsy may detect a low-risk malignancy. But there is always the chance it may have missed a not too friendly cancer. So the risk of under treatment does exist.

One also has to consider human psychology. Doctors have preached for years the importance of early diagnosis and treatment. So it’s hard for patients not to say, “Doctor you’ve diagnosed an early prostate cancer that may be not life-threatening, but you’re not going to do anything about it?”

Certainly, if you are in your late 60s or 70s, watchful waiting appears to be a prudent approach. As one famous U.S. urologist remarked to me, “Getting older is invariably fatal, cancer of the prostate only sometimes.”

But some patients find it impossible to live day after day knowing that prostate cancer is present even though it’s friendly. Klotz also reminds us that surgeons and radiologists make their living by operating and using radiation techniques to treat this disease, so there may be a tendency in that direction.

When a death occurs that should not happen it is a terrible tragedy. A tennis friend of mine once called saying, “I’ve had a PSA test that’s elevated, so my family doctor referred me to a urologist. Five biopsies of the prostate were normal. But he decided to do a sixth and it showed a bit of microscopic cancer. What should I do?”

He was 74 years of age so I told him to do nothing. Without treatment he would live at least another 15 years. But he could not accept living with a non-lethal cancer and agreed to a radical prostatectomy operation. He died of a pulmonary embolism as he was leaving the hospital, a totally needless death.

Unfortunately, patients and their doctors still need the Wisdom of Solomon to reach the right decision.

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