Prostate cancer has been an ignored disease for too long. What follows is evidence I use to support the concept of early detection with the present available tools. Although I decided to treat my cancer at diagnosis, I believe that is for each patient to decide to be treated or not. Prefereably from a knowledge base and not from fear or ignorance.

Evidence supporting early detection for prostate cancer

The negativity against early detection is driven by the US Preventive Services Task Force (USPSTF). This agency issued recommendations in 1996 and later updated the information in 2002. There is a certain hint of provinciality here in the U.S.A., if a study or clinical trial is not conducted in this country.

Evidence based medicine cannot be provincial as long as the studies are well designed and recognized as such by medical authorities. As it happens many key studies about the natural course of untreated prostate cancer were conducted in EU countries in which prostate cancer was not aggressively treated.

This information is vital to the issue of screening and early detection. Saying that it is not an American product is an anomaly when globalization is progressing at an accelerated rate and the world is becoming smaller by trading and communications. It is important therefore to review the recommendation of the USPSTF and counter them with current supporting evidence, irrelevant of origin.

Significant issues:

1. Prostate cancer mortality and its association with testing.

Since the inception of PSA testing in late 80s and more frequent use in the early to mid 90s, the mortality rate for prostate cancer has been reduced by more than 32% between 1993 and 2003. One of the critical aspects of the USPSTF recommendation is the inconclusive evidence that early detection improves health outcomes. The "real" evidence suggests that in spite of the expressed "widespread" use of PSA testing only 41% of men age 50 or above admit having a PSA within the last year. Men age 50 to 64 had a worse score. Only 33.6% admitted to have a test within the last year. In men 65 and above the figure is 51.3%. This alone is an indication that the "modest" reduction in the mortality rate is not that modest after all considering that the use of PSA is less common than proclaimed.

Source: Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 2003 Mar 15;97(6):1528-40. PMID: 12627518 [PubMed - indexed for MEDLINE]

More recently the Cancer Prevention Fellowship Program, Division of Cancer Prevention and Health Communication and Informatics Research Branch, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda published that 44.8% of men ages 50 to 75 had never had a PSA test in their life. Hardly widespread use in my view...and this fits the picture that we see at the support group level with many men diagnosed with more advanced disease than they should.

One of the main arguments I use against those that negate the value of
screening , early detection and early treatment is the unexplained reduction of prostate cancer deaths since the inception of what I define as limited detection by PSA testing. Request those opposing you to explain the reduction in mortality and the possibility to reduce deaths if more men
would be tested.

Evidence based medicine as expressed by the USPSTF seems to have selective biases in deciding what is good or bad and tends to ignore or minimize preliminary evidence. Such is the case with the extensive experiment carried out in Tyrol, Austria. This is a recent update of the study now going into its 12th year:

In 1993, a mass screening project using PSA as the only screening test was launched in the Federal State of Tyrol (one of nine federal states of the Republic of Austria). The aim of the Tyrol study was to monitor the impact of screening in a natural experiment by comparing prostate cancer mortality in Tyrol, where prostate-specific antigen (PSA) testing was introduced at no charge, with the rest of Austria, where it was not strictly organized and not free of charge. In 1993, PSA testing was made freely available to men between the ages of 45 and 75 years in the Federal State of Tyrol, Austria. Initially, only total PSA was measured, but free PSA measurement was added in 1995.

All of the men in this age range were advised and encouraged to undergo PSA testing; information to this effect was distributed to every Tyrolean man through print, radio, and television. The screening project was performed in collaboration with general practitioners, medical examiners, urologists, medical laboratories, and the Tyrol Blood Bank of the Red Cross. Informed consent was obtained from all of the volunteers participating in the program. During 1993, when PSA testing became freely available, 32.3% of all Tyrolean men between the ages of 45 and 75years underwent PSA screening and at least 70% of this population was tested at least once during the first 10 years of the study.

Tyrol is an alpine region in Western Austria with 631,410 inhabitants (at the 1991 census; 324,161 women and 307,249 men) in an area of 12,647 square kilometers. More than 96,000 men were screened at least once between 1993 and 2001. Of these men, 10,100 were between the ages of 45 and 49 and 4,900 were between 40 and 44 years of age. Thus, a substantial number of men between the ages of 40 and 44 were screened, justifying the inclusion of this age group in the analysis of the incidence and mortality rates.

From 1993 to 2001, 6024 transrectal prostate needle biopsies were performed. The overall prostate cancer detection rate was 30.2%. The incidence of prostate cancer in men between the ages of 40 and 79 in Tyrol increased from 1988 to 1994 and has remained constant. The incidence of organ-confined disease (stages 1 and 2) continued to increase from 1988 until 1998, although the incidence of extraprostatic disease (stage 3) declined after a peak in 1994. The incidence of metastatic disease (stage 4) has been declining since 1993. Since the beginning of the screening project, a significant migration to lower total PSA levels in patients undergoing radical prostatectomy has been observed. Subsequently, the rate of organ-confined disease in radical prostatectomy increased from 28.7% in 1993 to more than 80% in 2002.

The mortality from prostate cancer in Tyrol decreased significantly between 1993 and 2000, in contrast to a modest downward trend in prostate cancer death rates observed in the rest of Austria. On the basis of the age-specific prostate cancer mortality rates in Tyrol between 1986 and 1990, 39.6% fewer prostate cancer deaths in the age range of 40 to 79 years occurred in 1998 through 2000 than were expected.

The continued increase in local disease incidence, indicating that PSA testing detects early disease, and the constant decline in the incidence of prostate cancer that has distant spread at diagnosis in the population are encouraging. The decrease in prostate cancer mortality rates in Tyrolean men contrasts with the more modest change taking place among all men of the same age in the rest of Austria and provides evidence that screening and early intervention saves lives. Why then ignore this evidence? Those opposed will tell you that none of the treatments have been shown to improve survival (even though this is not totally true). This study is a unique experiment in that a whole community (a province of a country) was TESTED AND TREATED if diagnosed. The reduction in mortality there proves that early detection and early treatment saves lives. Such evidence should and cannot not be ignored.
Source:
Georg Bartsch, MD
Screening for Prostate Cancer: Updated Experience from the Tyrol Study
Current Urology Reports 2004, 5:220-225
Current Science, Inc. ISSN 1527-2737

Another piece of evidence comes from the U.S. in Olmsted County, Minnesota where early intervention by testing with PSA and DRE has been associated with a reduction in the mortality rate in that community.
Source:
Roberts RO, et al., Decline in Prostate Cancer Mortality from 1980 to 1997, and an update on Incidence Trends in Olmsted County, Minnesota. The Journal
of Urology; Vol. 161, 529-533, 1999.

2. Shift in diagnostic stage and its effects in outcome after treatment

Prior to the more frequent utilization of the PSA test (just 15 years ago) 70% to 80% of men diagnosed with prostate cancer were diagnosed with advanced stages of the disease. Now, because of more frequent use of PSA and DRE, 70% to 75% of men are diagnosed with earlier stages. There is no question that PSA and DRE are responsible for this shift in stage at diagnosis. There is also evidence that the outcome of treatment is better in lower stages of the disease. Obviously, treating an early stage represents an advantage in survival and impacts the mortality rate. To deny screening is to return to the past and the high rates of advanced disease.
Sources:
Gilliland FD, et al. Male genital cancers. Cancer. 1995 Jan 1;75(1
Suppl):295-315

Bianco FJ Jr, Wood DP Jr, Grignon DJ, Sakr WA, Pontes JE, Powell IJ.
Prostate cancer stage shift has eliminated the gap in disease-free survival in black and white American men after radical prostatectomy.
J Urol. 2002 Aug;168(2):479-82.
PMID: 12131292 [PubMed - indexed for MEDLINE]

Catalona, W. J., Smith, D. S., Ratliff, T. L. and Basler, J. W.:
Detection of organ-confined prostate cancer is increased
through prostate-specific antigen based screening. JAMA,
270: 948, 1993

Gretzer, M. B., Epstein, J. I., Pound, C. R., Walsh, P. C. and
Partin, A. W.: Substratification of stage T1C prostate cancer
based on the probability of biochemical recurrence. Urology,
60: 1034, 2002

The 5-year PSA-free survival rate for organ-confined PCa is 86% to 95% as compared to 78% for cancer with microscopic extraprostatic extension and 43% for those with seminal vesicle involvement. It is therefore very possible to extend survival by simply treating men before the disease escapes the prostate. If we add information such as the treatment results from The Lancet study, which showed a significant advantage to surgical treatment over conservative management for high grade PCa, we can be a bit more optimistic about the future of PCa and a reduction of the mortality rate.

Source:
Lu-Yao G. et al., Population-based study of long term survival in patients
with clinically localized cancer. The Lancet 1997; 349:906-910

Ohori M, et al Prognostic significance of positive surgical margins in
radical prostatectomy specimens. J Urol. 1995 Nov; 154(5):1818-24.

3. The overdiagnosis of prostate cancer. One more smoke screen

The more screening with PSA and DRE the higher the detection probability. Those that oppose screening claim that what they classify as a non-specific and non-sensitive marker (PSA) detects too many cancers that will not affect the patient in their life time. If this sounds like an oxymoron, it is because it really is. There is no doubt that over detection will occur. The real issue is what is the rate of over detection? Wild, off the wall anti-screening entities claim figures in the 50% to 80%. This is far from reality and they know it. If one accounts for the lack of "widespread" screening as mentioned above and the unexplained reduction in the mortality rate since the increased us of PSA testing, how could such high rates of overdiagnosis exist? Those overdiagnosed men would not affect the mortality rate by their classification of indolent cancers. Etzioni et al reported more rational rate of 15% to 37% at best depending on race.This is one more excuse without medical basis...

Source:
Ruth Etzioni, David F. Penson, Julie M. Legler, Dante di Tommaso, Rob Boer,Peter H. Gann, Eric J. Feuer
Overdiagnosis Due to Prostate-Specific Antigen
Screening: Lessons From U.S. Prostate Cancer Incidence
Trends. Journal of the National Cancer Institute, Vol. 94, No. 13, July 3, 2002

4. Other issues that qualify as Myths

A. Prostate cancer is an old man's disease.

Life expectancy in men is going up. At the beginning of the twentieth century male life expectancy was 57 years. At the end of the century it was 72 years. An extra 26% was added to the life span in one century alone. For most of written history, life expectancy in general was about 35 years, but technological advances such as antibiotics and vaccines and the improvement in hygiene and sanitation have had a tremendous health impact.

True, the risk and incidence of prostate cancer increase with age, but a full 25% of prostate cancers are found in men below the age of 65. Now, that represents around 40 to 50 thousand men every year diagnosed in their working years, the prime of life. Old age is now a moving threshold. As the population's general health improves and men avoid death from other causes, the risk of prostate cancer becomes more significant and awareness about such risk needs to be intensified.
Source:
Cancer Facts & Figures 2005 -The American Cancer Society

B. Most men die with prostate cancer rather than from prostate cancer.

This statement is a piece of misinformation in itself. Why? Because it ignores the fact that the prostate cancer that kills men is not the type of cancer commonly found at autopsy of men who die of other causes without ever showing any sign or symptom of prostate cancer. The type of cancer found merely at autopsy IS NOT histologically or in size comparable to the clinically significant cancer that progresses - and does so at a rate that causes death. All too conveniently, critics ignore this simple fact and use the prevalence of cancerous prostate cells to misinform and confuse the issue.
Source:
Villers A, et al [Prostate cancer screening (III): risk factors, natural
history, course without treatment. Characteristics of detected cancers].
Prog Urol. 1997 Sep;7(4):655-61. Review. French.

Sakr WA, et al The frequency of carcinoma and intraepithelial neoplasia of the prostate in young male patients. J Urol. 1993 Aug;150(2 Pt 1):379-85.

C. Early detection and treatments have not been proven to improve survival.

This has been used widely to avoid the cost of screening. As mentioned in
references above, the Tryrol study has demonstrated survival. The Olmsted County study also did. A newly reported update of the Holmberg study showed both disease-specific and overall survival benefit by those treated with surgery. This is a randomized clinical trial which cannot be ignored. For the first time a treatment for PCa demonstrated a survival benefit. Opponents to early detection and treatment keep ignoring the evidence. This is the world-wide confusion that is like an anchor around the neck of men at risk of prostate cancer...

Source:
N Engl J Med. 2005 May 12;352(19):1977-84.
Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S,
Spangberg A, Busch C, Nordling S, Garmo H, Palmgren J, Adami HO, Norlen BJ,
Johansson JE; Scandinavian Prostate Cancer Group Study No. 4.

Ralph Valle, Phoenix, Arizona 

Dear Friends,

I have just been told I can stop all cancer treatment. I am both ecstatic and terrified at the same time.

I wish to make it perfectly clear that I put a lot of my great results down to our network of PCa friends around the world.....and in my own case I have to say that the day Esteban introduced me to this site was a major turning point in my life.

Since discovering PCAinAZ and its marvelous chat facility, I have been on an upward learning curve. The great beauty of this particular site is the immediate one-to-one contact we have each week.

Time after time here, I have posed questions to which I was getting no coherent answers from my doctors. And, without fail, I was given the correct answers, the soundest of advice, and much much more. I don't think you guys realize what a remarkable collection of common sense, wisdom and PCa knowledge you have assembled here on this one small site.

As you may know, a TV crew was following the past six months of my fight, taking particular interest in how we guys around the world get together. I am not the only patient involved, we started at about 6. but sadly 2 of them passed away.

There is much more ground to cover, and in future months I think you'll see how sites such as your own feature strongly in the documentary. There must be no end to our fight against the curse of Prostate Cancer, a cruel, devastating disease. I may be "In remission" for a while, but I am no fool, and realize I can suddenly be brought down to earth with an almighty crash.

The fact is, I really WAS "written-off" after my biospy in April 2005. It seemed I only had 2 or 3 yrs to live...no treatment but 12-weekly injections of Zoladex (Lupron). T4 is SUCH a terrifying number to most people... INCLUDING medics who really should know better.

Because I used the internet and discovered the wealth of information available, I was able to return to the urologist within a week and demand a change of treatment plan. I was lucky. I found what I needed to know so very quickly.

So now, 30 months after the worst day of my life, I start a new chapter. Yes, I still have fear that the beast will return, but most of all I have confidence that I have a battalion of fighters alongside me. None of us need be alone in our struggle.

From the bottom of my heart, THANK YOU ALL,

George Hardy