A study just published online in the Journal of the National Cancer Institute (July 17, 2013) will no doubt create a firestorm of controversy within the urology community. Before we offer any comments or analysis, let’s give you the straight and skinny on the study.
Researchers performed autopsies on men who died between 2008 and 2011 from causes other than prostate cancer in Moscow, Russia, and Tokyo, Japan. During the autopsies the prostate glands were removed and prepared for pathology analysis. One experienced uropathologist analyzed all the slides using standard techniques.
Of the 320 prostates that were collected and analyzed, 37.3% of the Caucasian men (mean age 62.5 years old) had prostate cancer. So did 35.0% of the Asian men (mean age 68.5 years old). Roughly 40% of the men over 60 had identifiable prostate cancer and 60% of the men over 80 had prostate cancer. Most fascinating of all, nearly one third of all the cancers were scored Gleason 7 or greater, meaning that they would be considered aggressive, requiring surgery or some other invasive treatment. Over half the Asian men had a Gleason score of 7 or greater. [The Gleason score is a way of characterizing the severity or aggressiveness of the tumor. A Gleason 6 is considered mildly aggressive, whereas a 7 is often described as moderately aggressive and frequently leads to treatment.]
OK, before your eyes glaze over, let’s cut to the chase. We need to reemphasize that the men in this study did NOT die from prostate cancer. Most probably did not even know that they had prostate cancer. They may have died from heart attacks, strokes, accidents or some other cause. But when their prostate glands were examined, a high proportion had high-grade cancers. That is what is so astonishing about this study. Had these guys been living in the U.S. and getting screened with a PSA test, many would have been biopsied and nearly half of the detected tumors would have been considered so serious that they would have required prompt treatment (surgery, radiation, anti-androgen drug therapy, etc).
What are we to make of this research? The lead author, Dr. Alexandre Zlotta, is director of Uro-oncology at Mount Sinai Hospital in New York City. He and his colleagues introduce their research with this overview:
“The widespread use of prostate-specific antigen (PSA) testing has dramatically changed the prostate cancer (PCa) landscape, enhancing PCa detection at a more curable stage. The perverse effects of PSA testing have included the diagnosis of a considerable proportion of cancers that are probably indolent [slow to develop], carrying a low probability of progressing to clinically significant, lethal PCa. The lifetime risk for men in North America to be diagnosed with PCa is almost 17%, but the risk of dying from PCa is 3.4%.
“Although men with apparent indolent disease may be offered active surveillance, data suggest overtreatment of low-risk disease is a problem, with less than 10% of men electing active surveillance in the United States. As a result, men may suffer debilitating side effects such as sexual impotence and urinary incontinence.”
Dr. Zlotta was quoted by Reuters:
“The study suggests that the progression of early prostate cancer, including some more aggressive forms of the disease, is far from inevitable within a man’s lifetime as many such tumors are found in men who died from other causes when their prostate is analyzed on autopsy…The study concludes that it is probably worth re-examining our current definitions of clinically unimportant and clinically significant prostate cancer.” In the paper, Dr. Zlotta and his colleagues point out that “a large proportion of tumors are not destined to become life-threatening.”
BOTTOM LINE:
When most men are told that they have prostate cancer and that a biopsy reveals it is “aggressive” because of a Gleason score of 7, they are easily convinced they need prompt treatment. What this study reveals, however, is that the story is far more nuanced and complicated. Urologists do not know which cancers, even those with a Gleason score of 7, will remain “indolent,” not causing any worrisome disease and which will become a problem or lead to death. That leaves millions of men in a terrible bind.
We stumbled across a very thoughtful new book by a Jay Cohen, MD, who himself has been diagnosed with prostate cancer (Gleason score of 6). The title is Prostate Cancer Breakthroughs: New Tests, New Treatments, Better Options. We think it is worth a read for any man with newly diagnosed prostate cancer.
You may also find our interviews on prostate cancer worth listening to:
Prostate Cancer Puzzle (Free bonus interview with Dr. Katz)
Surviving Prostate Cancer (Free bonus interview with Richard Ablin, discoverer of the PSA test)
We would like to get your feedback on this new study. What do you make of it? How do the results affect your understanding of prostate cancer. Will it change your communication with your doctor? Please share your own experiences with prostate problems below.