Who Benefits From Prostate Treatment

March 2014

This is the intriguing title of an editorial in the January 2014 edition of the British Journal of Urology International and published coincidentally during a national advertising campaign to increase awareness of prostate cancer.

WidespreadPSA-based screening has dramatically altered the profile of newly diagnosed prostate cancer (CaP).When I was appointed as a consultant in 1984, over 60% of newly diagnosed patients had advanced, incurable CaP and soon died.Now that figure is around 20% with the vast majority of patients presenting with early, curable CaP;in other words, CaP that is still apparently confined within the prostate gland and curable through surgical removal of the whole prostate gland – radical prostatectomy –or radical radiotherapy to the prostate.Although there is no national screening programme for CaP, this change has largely been brought about by widespread use of the screening blood test Prostate Specific Antigen (PSA).

Latest trial data estimates that PSA-based screening can reduce the chance of dying from CaP by 50% which might cut the UK CaP death rate from nearly 11,000 to 6,000 a year.However, all radical treatments come at the cost of potentially major side effects such as impotence and incontinence.Furthermore up to 75% of PSA-detected cancers are thought to be low risk and non-lethal which raises the risk that they may be treated aggressively for no good reason.Because of this, active surveillance is now frequently used instead of aggressive treatment for carefully selected patients.The key issue thus becomes how to determine which patients are suitable for surveillance alone and who should undergo radical treatment.

Unfortunately there is little high quality evidence to guide prostate cancer treatment selection and most comparative trial data is out of date.However, in the latest trial (“SEER”), data on 33% of 28,000 US men diagnosed with “low-risk” CaP between 2004-2007 who underwent active surveillance shows that 5.4% have died from prostate cancer.Closer to home and more worrying, a cohort ofUK patients placed on active surveillance in 2002/3 are reported to have a 15% death rate from CaP (J.ClinUrol, 2014; 7,112-115).These studies highlight the limitations of diagnostic tests available at that time as those men dying were obviously not “low risk” (BJU Int 2014; 113: 43-50).Fortunately since then the availability of second line markers such as hK2 and greater use of MRI scanning with or without more extensive and better targeted biopsies already makes the above data out of date.In addition, minimally invasive treatments are being introduced with curative intent and which already show a much reduced side-effects profile.

What conclusions can we draw from this shifting pattern of information?

Firstly, PSA testing is here to stay until another cheap, simple marker becomes available.EN2, a simple urine test being developed in Surrey, may fulfil this role.

Secondly, PSA testing will and should continue to increase and men seeking a PSA must be told of the 50% reduction in mortality achieved by organised screening programmes.

Thirdly, our second line diagnostic tests have improved considerably within the last few years resulting in patients and urologists being able to make much better treatment choices tailored to an individual’s needs.But without early detection, men have no choice.

Fourthly, minimally invasive treatment with low side effects profiles are emerging but should only be undertaken within clinical trials.

In conclusion, we cannot abandon PSA testing and go back to 1984 when most men with CaP presented with advanced disease and died from it.Up to date evidence now strongly suggests that regular PSA testing from a man’s mid-forties to his mid-seventies will continue to cut the death rate from CaP.Although it is currently recommended that UK men seeking screening should be counselled according to guidelines in the Prostate Cancer Risk Management Programme, these are complex and poorly understood by both patients and GPs (J.Clin Urol 2014, 7, 45-54).Consequently for patients and particularly GPs counselling patients, we recommend following the advice drawn up by leading international specialists and published as the Melbourne Consensus (BJU Int, 2014, 113, 186-18) summarised here below.

Melbourne Consensus Statement:

Our strategy should therefore be to continue to offer men the opportunity for early diagnosis whilst minimising the risks of unnecessary aggressive treatment.

C M Booth