Questions By Pathologist at High Risk for Prostate Cancer

October 11, 2011 - The papers are full of news about a U.S. Preventive Task Force Decision not to recommend routine PSA screening of healthy men for prostate cancer.

About half of men over 50 now receive PSA-screening. It is estimated that 120,000 men die of prostate cancer, the second leading cause of male death after lung cancer, and although 16% of men have the disease but only 3% die of it.

The Task Force essentially said routine PSA screening does more harm than good, because of such things as infections after biopsy, agony over false-positives, over-treatment resulting in impotence and erectile dysfunction, and exorbitant fees for surgery, radiation, and hormonal therapy are unnecessary, especially in men over 75.

Associations of urologists, other doctor organizations, and an oncologist at Harvard disagree, saying prostate cancer, caught early, saves thousands of lives.

To treat or not to treat prostate cancer, based on elevated PSA levels and positive biopsies, that is one question. A second question is, why treat a slow-moving cancer that is not likely to kill the patient, who is five times as likely to die from a disease unrelated to his cancer.

Given this context, I would like my blog readers to answer a series of questions relating to my personal situation. I am a pathologist who in the course of doing hundreds of autopsies, knows that microscopic evidence of focal prostate cancer is present in about 65% of men over 65 and 90% of men over 90. I am in the 65 and over crowd. I am a high risk for prostate cancer for these reasons.

• Men with a family history of prostate cancer are at risk. My brother had his prostate removed at 55 for a PSA-detected prostate cancer without complications, and has been cancer-free for 15 years. My father developed prostate cancer has 75, had his cancer irradiated, and died of a stroke at 91.

• Over the last two years, my PSA has risen from 2.3 to 3.9, with 4.0 considered the outer edge of normality.

My questions are these:

• Should I, an asymptomatic male, go for another PSA?

• If elevated above 4.0, should I undergo a biopsy?

• If the biopsy is positive, should I; one, have the prostate removed; two, undergo hormone therapy; three, have the prostrate treated by conventional radiation or by a 5-day cyberknive therapy.

• Should I be a minimalist, i.e., someone who forgoes PSA-testing and therapy for a positive biopsy, or a maximalist, someone who opts to have the prostate out or treated aggressively by other means.

• Should I trust a federal panel focusing on saving money and doing no harm, advising no PSA-screening over age 65, no treatment over age 75, or on a urologist who will make money on any procedure who may cure me, relieving me of the anxiety of harboring a malignancy.

Not Trivial Questions

These are not trivial questions, given my situation, and given the growing consensus that men over 50 have a 50% chance of having microscopic prostate cancer, men over 60 have a 60% chance, and so on, up to 90% for men over 90.

It isn’t easy being a balls-bearing and prostate-bearing male, especially if one wants to remain upright and functioning into old age.

References

1. Michael Barry, MD, “Screening for Prostate Cancer – The Controversy That Refuses to Go Away,” NEJM, March 20, 2009.

2. Shannon Brownlee and Jeanne Lenzer, “Can Cancer Ever Be Ignored,” NYT Magazine, October 9, 2011.

3. Jennifer Corbett Doreen and Thomas Buxton, “Panel Faults Widely Used Prostate Cancer Test, “ WSJ, October 7, 2011.

4. Jerome Groopman, MD, and Pamela Hartzland, Your Medical Mind, The Penguin Press, 308 pages, 2011.

Tweet: A 65 y.o.+ pathologist at high risk for prostate cancer asks: Should I have a PSA test, and if elevated, should I have biopsy?