Men Are On Their Own: Analysing the Risks of Prostate Cancer Screening and Treatment

The US Preventive Services Task Force has issued a new statement on screening for prostate cancer that virtually eliminates any sanctions against doctors who perform needless prostate cancer treatment.

As background, in 2012 the same task force advised against PSA tests. Now a U-turn: instead physicians abrogate their responsibility to instruct patients by saying they have no specific advice on the topic of PSA tests and men can decide treatment options, including no treatment (active surveillance) on their own.

According to a news report published by the Daily Mail (UK), “The U.S. Preventive Services Task Force says routine PSA blood tests can slightly reduce some men’s chances of dying from prostate cancer.” [Daily Mail UK April 11, 2017]

Physician groups are cheering the decision as now they can continue to coerce fearful men into treatment they frankly don’t need. The decision to be screened for prostate cancer “should be an individual one” says the report. [Journal American Medical Assn. April 11, 2017]

The Task Force report concedes only 1 in 1000 men screened might avoid death from prostate cancer with screening. And the report did describe frequent and infrequent harms from invasive diagnostics (needle biopsies) and treatment.

The Task Force draft report says:

Over the next 10 to 15 years, if a 55-year-old man chooses not to get screened, his chance of dying from prostate cancer is about 0.6%. If he chooses to be screened, he reduces the chance of dying from prostate cancer to 0.5%—about a 20% relative reduction. Screening may provide him with the additional benefit of reducing his risk of metastatic disease. If he chooses to be screened, he has about a 25% chance of having a positive PSA test result at some point during screening that will likely require a biopsy with possible adverse effects of pain, bleeding, and infection. Overall, if he is screened, he has a 10% chance of being diagnosed with prostate cancer, with a substantial proportion of these cancers (20%-50%, based on the trials) unlikely to grow or spread. About 65% of men diagnosed with prostate cancer are treated with surgery or radiation soon after being diagnosed. An additional 15% have surgery or radiation treatment later after their cancer is found to have progressed under active surveillance; 75% of all those treated experience impotence, incontinence, or both as a result of these treatments.

Understand, we are dealing with patient fears here, not cancer itself. Once men undergo a biopsy and hear they have “cancer cells” (actually pre-cancerous cells called neoplasia, dysplasia or hyperplasia) you can peel them off the ceiling of the exam room. But as explained by the American Cancer Society, the existence of pre-cancerous cells is a great way to ignite needless fear and convince a naïve patient to undergo needless treatment. Many men have pre-cancerous cells in their prostate gland beginning in their 30s. [American Cancer Society]

The 2012 Task Force recommendations were not enough to keep fearful men from asking for PSA testing and for willing physicians to accommodate them. [Nature Reviews Urology Jan 2017]

A survey of the decision-making process for or against prostate cancer treatment reveals most men already make prostate screening decisions on their own. [Cancer Causes Control March 2017] That doesn’t mean they make the right decisions.

In fact, it appears the more who had ever discussed the advantages of PSA testing were more likely to have undergone the test than men who had no discussions with their physicians. [American Journal Preventive Medicine Aug 2015]

Up to 80% of cancers diagnosed by screening will never compromise a patient’s health had it remained undetected. [Prescrire International Sept 2012]

A substantial proportion of the US population with limited life expectancy receive prostate cancer screening that is unlikely to provide a benefit for such a slowly progressive type of cancer. [JAMA Internal Medicine Oct 2014]

Prostate cancer overdiagnosis is estimated to range from 1.7% to 67.0%. [European Urology June 2014]

Men are unaware when they submit to PSA testing they are jumping on a conveyor belt that leads to needless biopsies and side effects. Needle biopsies in laboratory animals resulted in significantly more metastases (spreading tumors) and suppression of immune factors in the connective tissue (microenvironment) surrounding solid tumors. [Neoplasia Nov 2014]

The Task Force has only issued draft recommendations and now awaits comments before turning their recommendations into policy.

Radiation treatment

Men want more convenient treatment options for prostate cancer treatment, even though they may not really have the life-threatening form of this malignancy.

More men with early stage prostate cancer are opting for short-course (two weeks) five-session intense radiation treatment instead of 40 treatment sessions over a period of two months. Men are opting for this treatment, called stereotactic body radiation therapy, or S.B.R.T., even though there is no data to show it prolongs survival, says a report in the New York Times. [NY Times March 20, 2017] Scarring, damage to adjacent tissues (bladder, urethra) are drawbacks of the treatment.

More concerning, radiation damages the tissues surrounding prostate tumors called the microenvironment or non-cellular connective tissue. Radiation is used to treat up to 50% of cancer patients and to manage 40% of patients who are considered cured. For years radiation oncologists ignored the deleterious effects of radiation on the tumor microenvironment. Once damaged by radiation, inflammation, and development of new blood vessels in the wound healing process may promote even more aggressive cancer. [Nature Reviews Cancer July 2015]

Living cells that are in contact with each other exhibit a signal that arrests further growth. Once cells are damaged, such as by radiation treatment, that cellular growth arrest signal may be lost and uncontrolled growth may result. Radiation therapy should be categorically abandoned for cancer treatment.

Concern over needless treatment has arisen. A growing number of urologists now own the equipment to deliver radiation treatment. A troubling report notes that men with unfavorable risks for prostate cancer were 53 percent more likely to undergo external beam radiation treatment (EBRT) when urologists own the equipment. [Reuters.com April 7, 2017; Prostate Cancer & Prostatic Diseases March 28, 2017]

Watchful waiting

If men can stand the anxiety of doing nothing, a recent survey shows there is no significant increased risk for spreading (metastatic) prostate cancer with active surveillance (watchful waiting) over a 15-year follow-up period. Here are the results of that study:

HOW CANCER PATIENTS GET TRICKED INTO NEEDLESS TREATMENT

The table below the far right column appears to show radiation and surgery are significantly better at reducing death rates for prostate cancer. But the far right column only expresses relative differences. In hard numbers, waiting out prostate cancer versus undergoing treatment only increases the risk of dying by about 1 more person per 100. If reduction of mortal outcomes is the true measure of effectiveness, ~97 men out of 100 would avert needless treatment including loss of urinary control while 3 of the remaining subjects would face a mortal outcome rather than 2.

Treatment# of men15-year survivalProstate cancer deathRelative difference
Active surveillance (watchful waiting)31596.9%2.8%
Radiation therapy31296.6%2.5%-12%
Surgical prostate removal (prostatectomy)36598.5%1.5%-47%

Source: Renal & Urology News March 27, 2017

According to the US Preventive Services Task Force, out of 1000 men age 55-69 screened for prostate cancer:

  • 230 will have a positive PSA test
  • 110 will actually be found to have cancer
  • 4-5 men will die
  • 120 men will have a false positive upon biopsy
  • 770 will test negative

Source: San Diego Union Tribune]

Men can have elevated PSA (prostate specific antigen) readings for various reasons (recent infection, recent ejaculation or prostatic inflammation from enlarged prostate), but advancing age is the primary PSA driver. At age 40 a PSA of 2.5 is within normal limits. At age 65 that can go up to 4.5 and by age 70, 6.5. [Huffington Post March 21, 2017]

Screening for prostate cancer with the PSA test detects cancer earlier, but that doesn’t translate into cancer patients adding any years to the end of their lives. Prostate cancer patients who develop the mortal form of the disease are still dying on the same calendar day regardless of whether their cancer was detected at an early stage or not. The more PSA tests that are performed the more prostate cancer that will be detected, making it falsely appear there is some form of an epidemic. [URO Today]

The World without PSA tests

Researchers are working furiously to treat prostate cancer less invasively. A new analysis of blood and urine enables doctors to determine the effectiveness of prostate cancer treatment without repeated biopsies. The test analyzes fatty droplets from proteins and RNA called exosomes. [Science Daily March 22, 2017] A non-invasive urine test may be able to discriminate high and low-grade prostate cancer some day. [Nature Reviews Urology April 19, 2016]

A more accurate and definitive way to accurately predict prostate cancer may be to determine ferritin levels within prostate tissues. Ferritin is an iron-binding protein. Males accumulate iron as they age. [Oncotarget March 2017] This is in contrast to blood serum levels of ferritin. [Journal National Medical Assn. May 2004]

Is vitamin D the cure?

Another recent development is the lower risk of prostate cancer among black men when their vitamin D binding protein levels are elevated. Men with the highest levels of vitamin D binding protein were 55% less likely to develop prostate cancer in one recent study. [Renal & Urology News April 10, 2017; Cancer April 3, 2017]

When vitamin D binding protein loses a sugar molecule it becomes Gc protein-macrophage activating factor (GcMAF), a very strong anti-cancer agent. This is the same GcMAF that health authorities are attempting to ban in the UK. [BBC News Oct 16, 2016] But how can you ban a molecule the human body makes to prevent cancer when healthy? Something is amiss here.

Just what can men use for prevention today?

Also in recent news is a report emanating from Oregon State University that a molecule found in broccoli, sulforaphane, has prostate cancer preventive properties. [Prostate Cancer News Today March 27, 2017; Journal Nutritional Biochemistry April 2017]

A striking report indicated the oral administration of 60 milligrams of sulforaphane for 6 months following prostate removal surgery markedly slowed the PSA doubling time. [Cancer Prevention Research Aug 2015]

A promising approach to management of prostate cancer is a combination of the trace mineral zinc and the red wine molecule resveratrol. Researchers note that zinc levels are diminished in cancerous tissues. Mega-dose zinc has been demonstrated to counter prostate cancer growth but such high doses may lead to adverse side effects. The combination of zinc + resveratrol (a copper binder) is proposed as an approach to abolishing or reversing malignancy. The combination of resveratrol + zinc increases zinc levels within prostate cancer cells. [Cell Cycle 2014]

At the Winthrop University Hospital in Mineola, New York, an active holistic surveillance program for prostate cancer patients has been underway since 2002. The overall survival rate is 99.6% over the period 2002-2015.

Winthrop dietary recommendations include eliminating red meats, dairy products, fried foods, and refined carbohydrates from the patient’s everyday diet. The protocol emphasizes consuming poultry, fish, green tea, soymilk, red wine, and flaxseed in place of carcinogenic foods. In addition, patients are encouraged to add more fresh vegetables to their everyday diet, with an emphasis on cruciferous vegetables and tomatoes. Cow’s milk is replaced with soymilk.

Dietary supplements include broccoli capsules, omega-3 oil, anti-inflammatory enzymes, vitamin D3, soy (genistein) extract, mushroom extract, lycopene.

Under the Winthrop University protocol, only 11.5% of patients actually underwent treatment. [Journal Nutrition Metabolism 2016]

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