Prostate cancer??!!

[Anonymous]

In 2018, the United States Preventive Services Task Force made the following recommendations regarding prostate cancer screening:

https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening

These recommendations were based on a single study that showed that men diagnosed "early" with prostate cancer lived about the same length of life as men diagnosed "late" with prostate cancer. They concluded that since screening and early detection of cancer was not extending life, and might result in a 5-10 minute uncomfortable procedure (a prostate biopsy), that we should reconsider prostate cancer screening. In doing so, they concluded, we can decrease the diagnosis of prostate cancer, and thus decrease the expensive treatment of prostate cancer which can result in harm to the patient. With Medicare spending out of control, and an increasing Medicare population (10,000 baby boomers retiring daily), if we don't screen, (they concluded) we won't diagnose cancer, thus decreasing expensive cancer treatment which results in saving Medicare money.

Here's the problem IMHO:

If I ask you what is more important to you, "how long you live, or how well you live", which would you choose? Truthfully, I think most would choose both. I want to live a long time and have a good quality of life. If you treat significant prostate cancer early, before it spreads, it can be cured. However, if you find it late, after it spreads, it can't be cured.

At that late point, the cornerstone of treatment is chemical castration (reducing the man’s testosterone to castrate levels through a certain pharmaceutical pill or injection) because testosterone makes prostate cancer grow faster. Doctors never use that term or conceal the realities of chemical castration, but it is what it is. Removing testosterone chemically slows down prostate cancer growth. Thus, with metastatic prostate cancer, and chemical castration, the growth of prostate cancer can be slowed to allow the person a normal length of life. However, testosterone is a large part of what makes males “male.” Without it, the patient will typically experience frequent hot flashes, lose all libido (sex drive), lose muscle mass and bone density, will be far more prone to early onset dementia, will usually experience depression, have much less energy overall, and the ability to focus decreases, etc., for the rest of life.

The linked statement above doesn't mention anything about chemical castration and living years with the side effects. And again, doctors are rarely honest about the full range of side effects of chemical castration therapy.

To make matters worse, the statement linked above clearly states that you should have a discussion with your patients and respect their decision whether or not to continue prostate cancer screening (i.e. an annual PSA blood test, and a rectal prostate exam or "DRE") between the ages of 55 and 69, and to not screen men over 70. This is based on an average life expectancy of 78yrs for males in the United States.

However, 78yrs is the average life expectancy, taking all comers, including those who die in car accidents in their 20's, heart attacks in their 40-50's, and those who live to 110. The longer you live, statistically, the longer you will live. Someone who is healthy at 65 has a better chance of living longer than 78 than someone who is 10 years old. Not everyone is going to die at 78. People are living longer and are more healthy longer than ever before.

What many primary care physicians and providers have taken away from that statement above is "I don't have to do prostate exams anymore". It doesn't say that! At my last physical, my Nurse Practitioner told me that she was trained that she shouldn't do prostate exams. I still requested one, and she refused.

Bottom line, not everyone with prostate cancer needs to be treated. Some men with low grade cancer can be watched and avoid possible complications of cancer treatment. However, we will miss the opportunity to cure the men with more aggressive cancers if we don't screen and diagnose the cancer before it spreads. Truth is, if you live long enough, you will likely get prostate cancer (if you are male). You will probably die with it, not of it. But some will die of it and it is a slow painful death for those men.

If you have a family history of cancer, or if you are African American:

-you should start screening at age 40 with an annual PSA and DRE (don’t take no for an answer).

If you have multiple family members with prostate cancer or a family member with high grade (aggressive) prostate cancer:

-you should get genetic testing to see if you are at risk. There are genes associated with prostate cancer that are also associated with an increase risk of pancreatic, breast and ovarian cancers.

Those with a strong family history of breast, ovarian, or pancreatic cancers, should also get genetic testing for those factors.

Otherwise start annual screening at age 50. After 70, the DRE is optional, but the PSA should be done as long as you are in good health. In fact, it's probably worth getting a PSA in your 40's just to be safe. If it's low (less than 1.5ng/ml) then wait until 50 to continue.

PSA should be age adjusted. Prostates grow with age and bigger prostates make more PSA. Someone in their 70's with a PSA of 4ng/ml is probably OK. And by that age the prostate will probably be enlarged anyway. But someone in their 50's should have a PSA less than 2.5ng/ml.