Prostate cancer

What disease does Warren Buffett have in common with Rudy Giuliani and Robert de Niro? Congratulations if your answer is prostate cancer. This curable, non-cutaneous neoplasm will strike about 17% of men born today and is estimated to be the second-leading cause of cancer-related fatalities in the USA. Genetics and a high-fat diet are risk factors contributing to disease development, although it is not known how these factors impact the natural course of prostate cancer in different races.

The lynchpin for early diagnosis is age-based, prostate-specific antigen (PSA)-based cancer screening in men at average risk (i.e., not African-American or without a genetic predisposition) [1]:

1.       Men <40 years of age: PSA-screening not recommended

2.       Men age 40-54 years: Routine PSA-screening not recommend in men between ages 40 to 54 years at average risk

3.       Men age 55-69 years: Recommendation is for shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on men's values and preferences.

4.       Men age 70+ years: Routine PSA screening is not recommended in men age 70+ years or any man with less than a 10 to 15 year life expectancy

The recent release of this guideline comes against a backdrop of controversy that has been brewing for decades about the possibility that PSA (which is not a prostate-cancer-specific biomarker per se) screening may lead to over-diagnosis and hence over-treatment of a largely indolent disease (interested readers are referred to The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster [authors: R. J. Ablin, PhD and R. Piana] for an overview).

How does this controversy affect the average patient who hears the dreaded diagnosis, and is then faced with an array of treatment choices ranging from active surveillance to brachytherapy? Definitive interventions (radiation therapy, hormonal treatment, surgery) are usually based on patient preferences, projected survival, and pre-specified risk assignment. Dr. Mark A. Rubin’s (Weill Cornell Medical College) research may offer hope to patients who wish to opt for active surveillance. Diagnostic and prognostic tests are being developed based on his team’s discoveries of prostate-cancer-specific genetic biomarkers. These tests will be used in conjunction with PSA and other clinical and pathological parameters.

Validated tests that are able to stratify patients into those with clinically insignificant disease and others with potentially fatal tumors will go a long way towards more effective prostate cancer management.

Source

1.            Carter, H.B., et al., Early detection of prostate cancer: AUA Guideline. J Urol, 2013. 190(2): p. 419-26.