Prostate Cancer/A Thread for Men and the Women Who Love Them

Beginning Prostate-Cancer Screening
At Age 40 Holds Benefits, New Data Show
November 7, 2006; Page D1
Most men don't start prostate-cancer screening until the age of 50. But now there's new evidence that starting at 40 could not only catch the worst cancers but could also spare men from unnecessary treatments later in life.

The idea of screening men at a younger age for prostate cancer is controversial. Widespread prostate-cancer screening has been blamed for unnecessary biopsies and overtreatment for prostate cancer.

While screening even younger men would seem to compound the problem, some new research suggests the opposite may be true. Scientists at Johns Hopkins University School of Medicine in Baltimore have shown that screening men at 40 can help doctors better interpret screening scores as men age, resulting, they say, in fewer unnecessary procedures.



Read Tara Parker-Pope's Health Mailbox2 where she answers readers' questions about medical studies, ailments and treatments.The screening test for prostate cancer is called the Prostate Specific Antigen, or PSA, test. It's a blood test that measures a protein produced by the prostate gland. As a result of PSA testing, about 1.6 million biopsies are conducted each year, but only 234,000 men are diagnosed with prostate cancer. The challenge for doctors has been how to interpret the results of a PSA test. Doctors generally view a PSA from 0 to 2.5 ng/ml as low, while 2.6 to 10 ng/ml is considered slightly to moderately elevated.

The new Johns Hopkins study shows that a single PSA score isn't all that useful, and that what really matters is the rate at which PSA scores change over time. Trouble is, most men start getting PSA tests at 50, and there's no historical PSA information to help doctors decide if a test score is worrisome or just normal for that particular man.

"We have been focusing on PSA as a marker of prostate cancer assuming that everyone who has a PSA that is elevated or going up is at risk for cancer, and that triggers a biopsy," says H. Ballentine Carter, professor of urology/oncology at Johns Hopkins. "But instead of using a single threshold, we should focus more on how fast the PSA got to a given point."

One problem with starting PSA screening at 50 is that many benign prostate conditions, such as inflammation or enlargement of the prostate, can cause spikes in PSA levels, making the test less reliable. However, if screening is started at a younger age, doctors will have more information about a man's prostate health over the years, helping them to distinguish between benign conditions, nonaggressive cancer and lethal cancers.

GAUGING YOUR RISK


Here's a look at some of the risk factors for prostate cancer:
• Having a father or brother with prostate cancer.

• Eating a diet high in red meat and high-fat dairy products.

• Lack of exercise.

• Being over 65 years old.

• Vasectomy before the age of 35.

• Annual increase in PSA score of 0.35 ng/ml or higher.


Source: American Cancer Society; Johns Hopkins University School of Medicine.The John Hopkins study, published this month in the Journal of the National Cancer Institute, looked at PSA scores from 980 men in the Baltimore Longitudinal Study of Aging, the country's longest-running scientific study of human aging. The researchers looked at the pattern of PSA scores, comparing scores from healthy men with those who died of prostate cancer. What was so notable about the review of the BLSA data is that it could predict 10 to 15 years before diagnosis which men were going to have life-threatening cancers, even when their PSA scores were still relatively low.

There are several ways the BLSA data can help men not only avoid unnecessary treatment but also to make better decisions about their care if they are diagnosed with prostate cancer.

According to Dr. Carter, a 40-year-old man with a PSA score of 0.6 or lower needs less frequent monitoring and likely only needs repeat tests at the age of 45 and 50.

However, if a 40-year-old has a score above 0.6, he should be checked every two or three years. Most of these men won't have cancer, but regular testing will develop a PSA history that will make it easier for doctors to interpret their PSA scores when the men are in their 50s and 60s.

The data show that a man whose PSA score rises by 0.35 ng/ml or more each year will see a fivefold increase in the risk of dying from prostate cancer in the next two to three decades. By finding those men in their 40s, doctors can intervene when the cancer is more easily treated and the man is less likely to have complications.

And using "PSA velocity" can help identify men who have slow-growing cancers that don't need any treatment.

For instance, a 40-year-old man who has a PSA of 0.8 at 40 and then a score of 2 a few years later likely is at high risk for aggressive cancer. But if he has a score of 2 and no prior PSA test, he likely would be told he's at low risk. By the time his PSA score reaches 4 and doctors decide to intervene, it might be too late to save him.

Meanwhile a 50-year-old man with a PSA of 4 likely will be told he needs a biopsy. However, if that man at the age of 40 had a PSA of 2, the 10-year trend suggests he likely doesn't have cancer or at least not an aggressive cancer.

"It's the same threshold of 4," says Dr. Carter. "But the two people got to that threshold at much different rates. I see this as a way to decrease the men who have biopsies and identify the men with lethal disease."

Interesting article. The usual "wisdom" was to have men checked for psa starting at 50, unless there were some reason that an individual had a high risk for getting the disease. Now the docs have realized that starting to test at 40 would certainly have its advantages.

Study Debunks Prostate Cancer Treatment 'Wisdom'

By ROB STEIN The Washington Post

Published: Dec 13, 2006

WASHINGTON - A large new study is challenging the common practice of recommending that elderly men forgo treatment for early prostate cancer and instead wait to see whether the malignancy progresses.

The study of more than 44,000 American men ages 65 to 80 found that those who chose to aggressively treat their prostate cancer with surgery or radiation were about 30 percent less likely to die than those who waited, indicating that treatment offered a clear advantage.

The research, published in the Journal of the American Medical Association, is the first to directly examine what has become the conventional wisdom that many elderly men need not treat early prostate cancer because it tends to grow so slowly that they probably will die of something else first.

"For many years the thinking has been that observation, or 'watchful waiting,' was the safest option for elderly patients with early prostate cancer," said Yu-Ning Wong, of the Fox Chase Cancer Center in Philadelphia, who led the study. "This suggests there may be a benefit of treatment, even in this age group."

The findings prompted debate among specialists, who said the results could have potentially far-reaching implications because they address one of the central quandaries about prostate cancer and because the disease is so common. It strikes 235,000 U.S. men each year and kills more than 27,000, making it the most common cancer and second-leading cancer killer, after lung cancer, among men. Most cases are diagnosed after age 65.

Some experts said they hoped the findings would encourage more doctors to consider treating elderly men.

"This debunks the idea that older men do not benefit from treatment," said Christopher Amling, of the University of Alabama at Birmingham. "This gives support to the idea that active treatment can be beneficial."

Others experts, however, expressed skepticism, saying the study's design may have missed another explanation for the lower death rate among men who were treated: They were probably healthier in ways that doctors can only tell by from examining them in their office, not from looking at their medical records, which is what the study's authors did.

"There was probably something about these guys that made them more likely to get treated that also made them more likely to survive," said Mark Litwin, of the David Geffen School of Medicine at the University of California, Los Angeles, who co-wrote an editorial accompanying the paper.

Please guys, have your psa checked. If you see it start to creep up, have a biopsy. If the doctor balks, go see another doctor. It is really not a terribly big deal. If my husband had been biopsied 5 years ago, when the psa was starting to rise, he would not be going through what he is.

Guys: the 35-50 age group is the fastest rising demographic in prostate cancer diagnoses. This is only because of more accurate testing. That age group probably had a higher incidence of prostate cancer than most people thought.

As with breast and colon cancer, familial clustering of prostate cancer has been reported frequently.[20-24] From 5% to 10% of prostate cancer cases are believed to be due primarily to high-risk inherited genetic factors or prostate cancer susceptibility genes. Results from several large case-control studies and cohort studies representing various populations suggest that family history is a major risk factor in prostate cancer.[21,25,26] A family history of a brother or father with prostate cancer increases the risk of prostate cancer, and the risk is inversely related to the age of the affected relative.[22-26]

The Prostate Cancer Genetic Research Study (PROGRESS)is a nationwide research project exploring why some families have several male relatives with prostate cancer.

Discovering the inherited genes for prostate cancer in families and how they work will hopefully provide new clues to help diagnose, treat, cure, and even prevent prostate cancer in future generations.

The Prostate Cancer Genetic Research Study is being conducted by Fred Hutchinson Cancer Research Center in Seattle, Washington.

This research is made possible by funding from the National Cancer Institute and the National Institutes of Health, with additional support from CaP CURE and the Fred Hutchinson Cancer Research Center.