Diagnosis and Treatment of Prostate Cancer

By Loeb, Stacy Md; Catalona, William J. Md | Medical Economics, December 19, 2008 | Go to article overview

Diagnosis and Treatment of Prostate Cancer


Loeb, Stacy Md, Catalona, William J. Md, Medical Economics


BEYOND THE CONTROVERSY OVER WHETHER AND WHOM TO SCREEN, THE APPROPRIATE METHOD OF SCREENING IS ALSO SUBJECT TO DEBATE

Prostate cancer is the second-leading cause of death in men in the United States. Consequently, there is considerable interest in the screening, detection, and treatment for this common cancer. Well-known risk factors for prostate cancer include increasing age and African-American race.1 A family history of prostate cancer is also a well-established risk factor, and recently, numerous single nucleotide polymorphisms have been identified that may lead to a cumulative increase in prostate cancer risk.2 Many environmental factors also have been associated with either an increased or decreased risk for prostate cancer (e.g., sunlight, dietary factors, and medications, such as statins).3-6

Unlike many other malignancies, symptoms are uncommon early in the course of prostate cancer. Instead, symptoms such as bone pain or obstructive or irritative urinary symptoms typically do not occur until the disease is advanced and/ or incurable. Accordingly, efforts are focused at detection of prostate cancer during the early, asymp- tomatic phase when the possibility of cure is more likely. Currently, the primary modalities used for early prostate cancer screening are the prostate-specific antigen blood test and digital rectal examination. Since the early 1990s, these two tests have been used together, in light of evidence demonstrating that they provide complementary information.

ONGOING CONTROVERSIES

Nevertheless, there are many ongoing controversies regarding best practices for prostate cancer screening. Specific issues of debate include the age to start and stop screening, as well as the optimal screening intervals.8 The age to start screening is controversial because prostate cancer is much less common among men younger than 50 years old, but baseline PSA measurements at a young age are highly predictive of later prostate cancer development and also enable the diagnosis of prostate cancer in some patients with early aggressive disease.9

The age to stop screening is controversial because of the long latency between prostate cancer diagnosis to the development of metastatic disease or death in many, but not all, cases. Meanwhile, the risk of death from competing causes increases with advancing age.

With regard to specific guidelines, both the American Urological Association and American Cancer Society recommend annual screening beginning in their 40s for high-risk men (African-American or positive family history) and beginning at age 50 for average-risk men.1 They recommend that screening be continued for men with at least a 10-year life expectancy. Furthermore, the National Comprehensive Cancer Network recommends a baseline PSA test for all men at age 40, the results of which are used to guide the intervals between later screening visits. This approach takes into consideration a growing body of evidence that the baseline PSA level at a young age is a strong predictor for subsequent prostate cancer risk.9

On the other side of the spectrum, the U.S. Preventive Services Task Force recently concluded that there is insufficient evidence regarding the harm vs. benefit of prostate cancer screening for men under age 75.10 However, they recommended against screening for men aged 75 and older. Despite these disparate recommendations from various professional organizations, prostate cancer screening is extremely common in the U.S. and many other countries.11

Beyond the controversy over whether and whom to screen, the appropriate method of screening is also subject to debate. PSA was initially approved by the Food and Drug Administration for prostate cancer screening in 1994, using a threshold value of 4 ng/ml for recommending a biopsy.

It is now known that the prevalence of biopsy-detectable prostate cancer is at least 15 percent among men with normal DRE findings and a PSA <4 ng/ml. …

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