Recently, I was asked by a member of the media how a man could “avoid prostate cancer.”
This is actually quite a challenging question to answer as one of the known risk factors for the disease is a family history of prostate cancer. It is estimated that between 5 to 10 percent of prostate cancer cases are caused by certain inherited genetic factors. Studies show an increased risk where there is a father or brother with the disease.
Medications given to help certain at-risk patients avoid developing prostate cancer have shown to be marginally effective and not widely adopted due to side effects. Recent reports on a study undertaken at Boston University and Harvard University sought to equate greater ejaculation frequency among different age groups with lower reports of prostate cancer, but the study did not allow for the exclusion of other factors on this supposed connection.
Other lifestyle recommendations such as avoiding smoking are certainly advised, but there is no prostate cancer avoidance strategy.
Prostate cancer can be a slow-growing disease that may not require treatment, but it also can be an aggressive, fast-growing cancer that does. Next to skin cancer, it is the most common cancer in American men. Risk for the disease increases with age, with it rarely seen in men under 40.
One practical response to maintain prostate health is for men to keep that annual checkup with their primary provider.
African-American males, men whose father had prostate cancer under 60 years of age and those with specific inherited cancer syndromes are among those considered at high risk for the disease. Genetic counseling may benefit some families.
The two tests aimed at reducing prostate cancer death by early detection are a digital rectal exam to check for abnormalities, and the prostate-specific antigen (or PSA) blood test to check for a substance made by the prostate.
This latter screening has become a contentious issue. It was widely adopted in the mid-1990s and resulted in a large effort, supported by professional and cancer patient advocacy groups, as well as hospitals and equipment manufacturers (such as the makers of robotic surgery equipment and advanced radiation therapy machines).
The result was a dramatic increase in the number of prostate cancers diagnosed, that seemed to be coupled with a slow, but steady year-on-year decline in prostate cancer mortality since 1996. This was used as evidence to show that we were making strides in prostate cancer death reduction through screening about eight years after the widespread adoption of PSA testing.
At that time, no randomized control trials were conducted to determine if this approach was truly effective in reducing prostate cancer mortality, and more importantly, all-cause mortality (because cancer treatment can and often does lead to many side effects and occasionally death).
Since then, a number of studies have been performed to try to clarify the role of PSA screening in men. Of the studies, only the European Randomized Study Screening for Prostate Cancer demonstrated reduced prostate cancer mortality, but only in Sweden and the Netherlands. Other European countries did not show that result.
The U.S. Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial failed to demonstrate a benefit for screening and in fact raised questions about the negative impact of followup medical procedures. A challenge in conducting these studies is that it takes eight to 12 years to start seeing an impact on mortality as a result of prostate surgery or radiation treatment, given that many prostate cancers grow very slowly.
The overall sense of impact of PSA-based screening for prostate cancer is that a small number of men will benefit by having therapy for a cancer that could shorten lives if not treated, but many more may be harmed by treatment without having had their lives threatened by the prostate cancer that was detected.
Not all cancers, if untreated, will kill. Without screening, five men in 1,000 will die of prostate cancer, while approximately four in 1,000 will die of prostate cancer if they undergo PSA screening.
Still, it is estimated by the National Cancer Institute that more cases of cancer in the prostate gland go undetected during a patient’s life than those that are clinically detected.
“So, should a man be screened for prostate cancer?” It depends, and requires a careful discussion with his physician about the benefits, and risks of such screening, and about his own risk factors for the disease.
Dr. Wilson C. Mertens is vice president, medical director cancer services Baystate Regional Cancer Program. He is one of several Baystate health professionals who contribute a column to this space each month.