Department of Urology, State University of New York Upstate Medical University, Syracuse, New York 31210, USA.
Recent guidelines recommend that men older than 75 years should not be screened for prostate cancer. However, increased life expectancy and the development of less invasive treatments have led to an interest in characterizing prostate cancer in elderly men. We determined how prostate cancer pathological characteristics differ in men older vs younger than 70 years.
We studied differences in prostate cancer pathological characteristics in autopsied glands from men 70 years old or older and compared findings to those in men younger than 70 years. All men died of causes unrelated to prostate cancer. Prostates were whole mounted at 4 mm intervals. Histological analysis was done to identify and characterize each cancer focus observed. Tumor volume was measured by computerized planimetry. Cancer was defined as clinically significant or insignificant based on established histological characteristics.
Of 211 prostates evaluated 74 were from men 70 years old or older. We identified cancer in 33 men (45%) in this age group vs in 26 of 137 (19%) younger than 70 years (p < 0.001). Men older than 70 years had significantly larger cancer and more clinically significant cancer (64% vs 23%, p < 0.005). Older men had more advanced stage cancer and greater Gleason scores (p < 0.001).
In an autopsy study of men with no history of prostate cancer those older than 70 years were more likely to have larger and higher grade prostate cancer than younger men.
Delongchamps NB, Wang CY, Chandan V, Jones RF, Threatte G, Jumbelic M, de la Roza G, Haas GP. Are you the author?
J Urol. 2009 Sep;182(3):927-30.
must remain a free choice.
Reproduced from the British Medical Journal with permission.
Charity letters asking for donations are a fact of life. This morning, however, there was a charity letter asking not for my money, but merely my support. The "Ignorance Isn't Bliss" campaign—launched this week and run by the Prostate Research Campaign UK with support from AstraZeneca—wants me, as a general practitioner, to display posters, and disperse leaflets encouraging women to use the "carrot and stick" approach to "persuade your man to talk to his doctor about his prostate health." This campaign is different: it is for prostates, but for women.
Sisters, we are being encouraged to "leave medical information leaflets lying around where he is likely to find them—i.e., the bathroom, near the remote control or the car seat." Women are wanted for our nagging abilities—and if you can't do it face to face (by "tugging at his heart-strings—do it for me/us/the family, as it means such a lot"), we are to do it by stealth. We are encouraged to lie, deceive, pressurise, and whine till we get our own way ("Book a double appointment with the doctor for a check up for the both of you, and tell him he's going with you.")
“We are encouraged to lie, deceive, pressurise and whine till we get our own way”
I have no doubt that the people behind this campaign are sincere people who want to reduce deaths from prostate cancer. On that I fully support them. However, I can't support this campaign.
Why? If I were the general practitioner responsible for "checking up" a competent adult pressurised into coming to see me, I would feel rather troubled. Firstly, what check up? We offer few screening tests that are clearly effective and none that are entirely harmless. The Prostate Research Campaign's leaflet tells us that as men get older "regular check-ups... are even more necessary." To be fair, the accompanying letter from professors of oncology and urology makes clear the controversy surrounding prostatic specific antigen (PSA) testing, but the leaflet, intended for women to arm themselves with information before tackling the household male, does not. It merely states that one in three men with a high PSA will have cancer, and that "his chances are greatly improved by early diagnosis and early intervention."
This I object to. If one thing is clear, it is that PSA testing is highly contentious and unproven as an effective screening tool; and there is a good argument that the test should not be done at all unless as part of a trial—for example, the ProspecT trial. Until this study reports, PSA screening cannot be advocated for the population—and certainly not for an individual without circumspect consideration. While GPs are obliged to offer a PSA test, after counselling, the unfortunate conclusion I fear from reading the leaflet is that good men get PSA tests done, and good women make sure of it.
The idea that the only good citizen is one who has screening tests is, to me, abhorrent. I wonder what would happen if the situation was reversed. I would not enjoy being shepherded into my
local health centre by my husband for a cervical smear. No competent adult should be cajoled or manipulated into doing what someone else thinks is best for them. Adults are capable of making their own decisions about risk, but they need good, honest information to do that.
There is a danger to the culture of "awareness." While knowledge is power, it is only functional if harnessed to disperse and aid decision making properly. Otherwise, well meaning campaigns are in danger of worrying the well and failing to reach the very people who may be most likely to benefit. While superficially the idea of increased awareness of prostate disease seems intuitively correct, the idea that women should seize responsibility for men's health implies that men are incapable of making their own decisions or getting their own information. This could be seen as patronising and even emasculating.
‘No competent adult should be cajoled, or manipulated,
into doing what someone else thinks is best for them.’
Are there not other ways that could better improve male health? For example, there is surely a need for further research into how best to get clear information on health directly to boys and men. Or how access to health services should work for symptomatic men—do we need to provide more of a "barber shop" walk-in service rather than the current "salon" style, pre-booking arrangement that currently dominates in general practice?
Whatever other work needs to be done, meanwhile it should be made clear that engaging in screening is a free choice, which may or may not have benefits, and significant side effects. Over the last few years many unproven screening tests have become widely available. Besides the cost to the NHS the potential detrimental cost to the individual is lost somewhere in the feel-good, check-up, on-the-safe-side, do-the-right-thing vibe. It should not be. I agree with the Prostate Research Campaign that ignorance is not bliss. But ignorance of the implications of false positives, false negatives, potentially unnecessary invasive interventions, and the current lack of evidence to support PSA screening—that is not bliss either.
I was alerted to this article by Mr. B. who sent me a copy. His comment with his letter was ‘I suppose we could not expect Margaret McCartney to write, “no doubt the people behind the campaign have mixed motives, not all entirely altruistic”’
Surely AstraZeneca who are paying for the campaign should by law have to state that they make Zoladex - probably the main drug (hormonal treatment) for prostate cancer. It follows that the more men who are diagnosed with PC then the more ‘customers’ they can anticipate. There is no world wide agreement that early treatment for early detected prostate cancer is beneficial. Placing a man on hormone treatment for possibly in excess of ten years, during which time he probably would not have had any symptoms caused by prostate cancer, but would certainly have drug side-effects during such an extended period on hormonal treatment, is not, I feel, an ethical way forward.
After decades of hormonal treatment for men with prostate cancer, it now transpires that there is a risk of giving such treatment to men as it may increase the risk of death for men with coronary artery disease. This follows work reported in the Journal of the American Medical Association for August 26 2009. How many treatments divised by our pharmaceutical companies turn out to cause death or other major side effects ? Lately Tamiflu seems to fit the bill !!
Prostate Cancer ….. Decision Time.
"For men who've had a prior heart attack or heart failure, use of hormone therapy for prostate cancer was associated with a shortened lifespan," said study author Dr. Akash Nanda, a radiation oncology resident with the Harvard Radiation Oncology Program at Brigham & Women's Hospital/Dana-Farber Cancer Institute in Boston. The report appears in the Aug. 26 issue of the Journal of the American Medical Association.
The findings essentially change the risk-benefit profile when deciding which treatment suits which patient, and could change practice fairly quickly, said Dr. Ronald D. Ennis, director of radiation oncology at St. Luke's-Roosevelt Hospital Center and associate director of Continuum Cancer Centers of New York in New York City.
"I think this is going to make people even more conservative in their use of hormones than when researchers started to identify who benefited," added Dr. Eric M. Horwitz, acting chairman of the radiation oncology department at Fox Chase Cancer Center in Philadelphia. "We had always thought that there might be cardiac problems with long-term use of hormones, but this shows that even a short course can be harmful."
Nanda and his colleagues looked at more than 5,000 men, average age about 70, with localized or locally advanced prostate cancer who were treated with radiation therapy alone or radiation therapy plus hormone therapy. Participants were followed for close to five years.
Hormone therapy was not linked with a higher risk of death from any cause in men who had no underlying cardiac conditions or only one risk factor for coronary artery disease.
But men who had congestive heart failure or who had suffered heart attacks as a result of coronary artery disease had almost double the risk of death, the researchers found.
"But for men who have more aggressive cancer, several clinical trials have shown that adding hormone therapy to radiation actually leads to an increase in survival and so, for this cohort of men, our results would suggest that if they do have preexisting heart disease that either hormone therapy not be used or that their underlying heart disease be initially addressed by their primary care physician and/or a cardiologist," Nanda added. "The risks need to be balanced with the benefits. For more advanced disease, the primary treatment is a combination of hormone therapy and radiation. So, for them, it becomes a little more tricky."
Cutting the waiting lists.
If you are diagnosed with prostate cancer, then choices have to be made. Which ever choice you make, you would expect that your treatment is the ‘standard’ treatment and not inferior in any way. In issue 3/2003, I indicated a possible patient risk of inadequate treatment in the radiotherapy sphere. A short piece in ‘Urology’ stated the importance of high radiation doses (72Gy or greater) in the treatment of stage T1-T3 prostate cancer. A member wrote to say he was told he was to have 55Gy. A comment was made that the treatment centre could not cope with the volume of patients at the higher dose rate.
‘Patients receiving radiation doses of 72 Gy or higher had a significantly better outcome. The improvement was seen in all subgroups of patients. If these results are confirmed, radiation doses exceeding 72 Gy should be considered the standard of care.’
The above conclusions were based on a trial of over 700 patients over a five year period.
( Side-effects not advised.)