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Is a mortality reduction the only desirable benefit of prostate cancer screening?

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User
Posted 11 Mar 2018 at 14:02

There has been extensive reporting in the UK media this week of the study conducted in the UK (published in JAMA) that appear to suggest that a single PSA screening test is of no benefit, as it does not seem to reduce prostate cancer-specific mortality. However, the authors of this study have acknowledged the limitations of their study, such as being based on a single PSA test, having limited follow-up of only 10 years, and not having used the new multiparametric MRI modalities that may allow better targeted biopsies.

A previous European study (ERCP, published in the Lancet in 2014) had produced different findings with screening at regular intervals resulting in some reduction of the prostate cancer mortality, particularly when the analysis was extended beyond 9 years.

I do not know for sure what other prostate cancer patients think but, in my opinion, mortality is only one of the outcomes of interest. When I attend the local prostate cancer support group meetings the main message I get is that those patients who had a curative intervention (prostatectomy or radiotherapy) seem to be reasonably happy and most of them report to have tolerated reasonably well their treatment modality. Conversely it is our fellow patients on androgen deprivation treatment that seem to suffer more from severe or unpleasant and longer-lasting side-effects of treatment. The recent British study did report that the intervention group receiving PSA screening had a higher proportion of cases with lower grades or stages, which might translate in a higher proportion of prostate cancer curative interventions (surgery or radiotherapy) and a lower proportion of prostate cancer patients requiring eventually androgen deprivation treatment. Some published studies have shown that there may be an association between a lower health-related quality of life and receiving multiple therapeutic interventions or specifically receiving androgen deprivation treatment.

In our misfortune, we are lucky to be suffering from a type of cancer with a relatively low 10-year mortality. So, what would really be of interest to me, would be to know what are the differences between the screening and the control group in the proportion of prostate cancer patients eventually requiring androgen deprivation treatment, and also any differences in the health-related quality of life as a result of different treatment modalities associated with later diagnosis, that might be used more frequently in the group not undergoing screening. Quality of life is at least as important as its length.

User
Posted 12 Mar 2018 at 00:26

There are times when a single PSA test does not raise suspicion and there are no other indications that there might be PCa and some of these men who actually have PCa may nevertheless live for many years and die because of something else in the same way as men who don't have cancer. Others develop symptoms or because of other suspicious indicators go on to have further tests which may or may not indicate PCa. Then there are those that have the PSA test and along with other indicators are diagnosed with PCa. They are treated with various stages and degrees of PCa. The lifespan of some of these men will not be increased by their treatment because their cancers will not sufficiently advance before they die of something else so they will have suffered the side effects of treatment unnecessarily it has to be accepted.

Now consider the men who have a PSA test, the usual instigator for further tests and treatment and consider what positive difference this can make to them. The very lucky ones, (usually diagnosed at an early stage), are cured. Others have two treatments and are then cured. Then there are those that go on to have several treatments and they are not cured but the treatments hold back the advance of their cancer giving them additional time that they would not have had without a diagnosis, usually initiated by the PSA test. Knowing your situation also concentrates the mind on doing the important things and making dietary changes that may help. Certainly, all these treatments come with the downside of side effects to varying degrees and some men at a certain point may say enough is enough, whilst others accept treatment to the end.

For some, having that first PSA test leading to treatment will mean that if they are not cured and their lives may be extended with a number of them dying of something else, thereby avoiding the horrible death that we know PCa can bring. Some
men who have PCa but are not screened may therefore be lucky and their cancer not progress whilst others will eventually be diagnosed at a late stage and need some forms of treatment even of a palliative nature.

Considerable effort is being made now to try to establish whether a man has an indolent cancer or one that really needs treatment and also to find a better test than the PSA one. Treatments are also improving both in terms of effectiveness and minimizing damage. More reason to have the initial PSA test and treatment on best assessment in my view.

Barry
User
Posted 12 Mar 2018 at 02:55

I for one am very pleased to have had a recent random PSA test, as subsequent investigations disclosed a T2a, Gleason 4+3=7 tumour despite me having no other symptoms. I can now take steps to deal with it before the situation gets any worse.

Here’s a BBC interview from last week with a professor about PSA testing:

https://www.santishealth.org/in-the-news/

Edited by member 12 Mar 2018 at 06:14  | Reason: Not specified

 
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