Prostate Cancer: Progress in Detection and Treatment

Until recently, prostate cancer was considered by many to be a disease of “old men” only.  As a result, science for the detection and treatment of prostate cancer was lagging decades behind that of breast cancer.  In fact, it was commonly believed that if doctors performed a biopsy on the prostate of all men eighty years old or older, at the time of their death from non-prostate related issues, we could expect to find evidence of undetected prostate cancer in close to 100% of those patients.

The discovery and use of the PSA (Prostate Specific Antigen) led to detection of prostate cancer in younger men. The PSA test was fairly inexact and could become elevated as a result of any of several non-cancerous conditions. It led to numerous biopsies in men who had no clinical findings consistent with prostate cancer but who turned out to have the disease. These young men were treated aggressively, and at times the treatment was as bad if not worse than the disease. The problem was that when we found a prostate cancer we had no idea if it was destined to be aggressive or whether it was going to lie quietly and be indolent for decades.

Different treatment strategies emerged in Europe and the United States.  In Europe the PCA3 test was employed to detect genetic markers of men with elevated PSA’s and normal prostate gland examination who should be biopsied. This test is now gaining acceptance in the USA.

In a February 2011 article published in Nature magazine, researchers announced that they had found a genetic test for prostate cancer  samples that predicted whether the disease would be aggressive (and spread) or not. This new test, coupled with the existing Gleason scoring system, accurately predicted who needed to be treated aggressively and who could be watched instead. A commercial version of this genetic test should be available within two years.  At the same time, another article showed that in patients with minimal prostate cancerous disease, it is safe to observe them rather than aggressively operate on them immediately.

Health experts recommend all men 40 and over have a digital rectal exam on an annual basis. The decision to obtain a PSA is based on history, family history of prostate disease and clinical exam of the prostate. There are no current recommendations by the US Public Health Task Force on Preventive care for screening for prostate cancer with a PSA level. Despite this, I generally obtain a PSA annually on men over 50 after explaining to them the pros and cons of following the current guidelines.

If the new genetic test to predict prostate cancer aggressiveness turns out to be as accurate as suspected, we are finally on the road to being able to treat those who need aggressive treatment and spare others who don’t.