Prostate Cancer in the News

An RWJ Library of the Health Sciences

interview with

Dr Olweny

 Ephrem Olweny, MD Urologist


more conversations

 

Q: Recent media reports on prostate cancer screen have focused on a US task force conclusion that screening for prostate cancer was not working and recommendation that screening should be stopped.  Yet, physicians still screen a lot of men each year.  Who are we supposed to listen to?   Should healthy men get screened or not?


The American Urological Association (AUA) has issued clear guidelines regarding prostate cancer screening. These guidelines take into consideration the USPSTF (United States Preventive Services Task Force) recommendations, but they obviously do not match them entirely. see here for details

Q : Why not?  Is there a problem with the task force’s recommendation?

The USPSTF recommendation against screening was heavily weighted on the results of two randomized studies on screening, namely the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Prostate, Lung. Colorectal and Ovarian screening trial (PLCO).  Unfortunately, both studies were flawed and limited. see here for details

Q : Has prostate cancer screening saved lives?

Yes. Prostate cancer-specifc mortality in the US has been reduced by about 40% over the past 20 years, largely due to PSA-based prostate cancer screening.

Q: The New York Times recently reported on new prostate cancer tests.  How do they differ from the PSA test?  

Many of these are genetic based tests that simultaneously analyze multiple prostate cancer-related genes, in contrast to PSA which is protein-based.   

Q : What are some of the new tests?

PCA3, Prolaris, Oncotype DX, ProstaVysion, Decipher™ see here for details 

Q : Are we ready to replace the current PSA test with the new ones?

In their current form, these new tests do not replace conventional screening tests.

Q:  In the treatment of patients with prostate cancer, a large number of prostatectomies are performed each year with robotic surgery systems.   Are these systems safe?

The first robotic prostatectomy in the United States was performed in 2002 and the technique has been rapidly adopted since, such that the vast majority of prostatectomies performed in the US today are done using the da Vinci system. Experienced surgeons have accumulated more than a decade of experience with robotic - assisted radical prostatectomy, with an excellent overall safety profile. It is important to note that adequate training and experience with the platform are critical prerequisites for good outcomes.

Q:  What are the benefits of robotic surgery systems for urology patients?

Benefits to the patient include smaller incisions, faster postoperative recovery, decreased blood loss and potentially earlier recovery of continence.

Q:  Is robotic surgery for prostate cancer any better than open surgery?

The short-term outcomes [that I just listed] are at least at par with those for open surgery.

Q:  Is prostate cancer preventable? 

There is a wealth of epidiemiologic evidence supporting the role of environmental factors in the pathogenesis of prostate cancer. Accordingly, over the past 2 decades, there has been a surge of interest in agents or strategies to prevent prostate cancer. Although there are conflicting results for some studies, some interventions have shown positive effects in the majority of cases. see here for details

 Q : Can you explain some of the science behind PSA?

PSA is an enzyme that is produced by the epithelial cells of benign and malignant prostatic tissue. Its biological role is to liquefy the semen, enabling sperm to swim more freely.  It is detectable in the serum where it is measured by radioimmunoassay. Although it is primarily produced by the prostate gland, it is also present in smaller quantities in salivary glands.

 


Dr. Olweny is an Assistant Professor of Urology in the Division of Urology / Department of Surgery at Rutgers-Robert Wood Johnson University Hospital. He specializes in minimally invasive urologic surgery encompassing both oncologic and benign conditions of the kidney, bladder and prostate, as well as kidney stone disease. He chairs the Clinical Competency Committee of the Urology residency training program at Rutgers-Robert Wood Johnson Medical School and serves on the Robotics Steering Committee at Rutgers-Robert Wood Johnson University Hospital. 
Contact: Ephrem Olweny, MD. olwenyeo@rwjms.rutgers.edu

 


 

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Prostate Cancer Screening Guidelines (2013)
American Urological Association

 

40 - 54


A young, healthy man (40-54) at high risk for prostate cancer (African American race, family history of prostate cancer) should discuss his decision to screen with his health care provider(s), and arrive at an indivualized decision on how to proceed.

 

55 - 69


Men ages 55-69 years at average or high risk for prostate cancer should participate in shared decision making on screening with their health care provider(s), after taking into consideration not only the potential benefits and harms of screening, but also individual personal preference. The greatest benefit of screening appears to be in men within this age group.

 

70+


Routine PSA screening in men 70+ years of age, or in any man with a less than 10-15 year life expectancy is not recommended

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Studies Used for Current Recommendation Not To Screen for Prostate Cancer

The PLCO concluded that screening did not reduce the risk of prostate cancer-related deaths over 10 years of follow up. However, this study was flawed due to the high rate of screened men in the control group which likely resulted in underestimation of the screening benefit.

The ERSPC was first published in 2009 and reported a 20% reduction in prostate cancer-related death over 9 years; however, 1,410 men would need to be screened and 48 men diagnosed to prevent 1 death. This benefit was considered modest by the USPSTF, outweighed by the large numbers of men needed to be screened and/or diagnosed, and thus subjected to the harms of intervention. However, in an updated analysis of this trial published in 2012 (after the USPSTF analysis), with follow extended to 14 years, the risk reduction in prostate cancer mortality improved to 44% in favor of screening in men aged 50-64.

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New Tests for Prostate Cancer Detection

PCA3  - PCA3 is an urine test that detects prostate cancer gene 3 RNA. It is useful in detecting malignancy in men suspected to have prostate cancer based on DRE (digital rectal exam) and/or PSA findings, but in whom one or more prostate biopsies are negative.  It could thus help avoid unnecessary repeat biopsies. However, it has a few limitations that require additional investigation into its diagnostic role.

Prolaris (Myriad Genetics) – The Prolaris test is performed on prostate tissue samples obtained by biopsy or surgical removal. It has proven to be a useful test for identifying patients at risk for disease progression after prostatectomy.

Oncotype DX (genomic prostate score) – Oncotype DX is a genomic prostate test that was developed for use with prostate needle biopsy specimens. An early clinical validation study has demonstrated that it improves prediction of high-grade and/or advanced stage prostate cancer. This test could help minimize the negative impacts of under-sampling during conventional prostate biopsy.

ProstaVysion  - ProstaVysion is a test that measures 3 genetic markers linked with prostate cancer. Alterations in all 3 genes signifies a poor prognosis while triple negative findings confer a favorable prognosis.

Decipher™ (Genomic Prostate Cancer Test) – DecipherTM is a test that measures 22 genomic biomarkers associated with the spread of prostate cancer.  A clinical study demonstrated that it is highly predictive of the progression of cancer beyond the prostate.

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Possible Ways To Prevent Prostate Cancer

Selenium and Vitamin E

Selenium and vitamin E have individually been shown in observational studies to  reduce prostate cancer risk, but a randomized controlled trial combining these agents, the SELECT trial,  found no favorable effect of selenium or vitamin E on prostate cancer prevention.

Weight Loss

Weight loss has been linked to reduction of prostate cancer risk, and in men diagnosed with prostate cancer, obesity has been correlated with advanced or aggressive disease.

Fat Intake

Total fat and animal fat intake in large quantities has been linked to an increased risk of prostate cancer

Lycopene

There is some evidence for the beneficial effects of lycopene, found in tomatoes and watermelon, in reducing prostate cancer risk

Soy

Data on soy intake are conflicting, but overall provide limited evidence for the effectiveness of soy intake and preventing prostate cancer.

Charcoaled Meat

Excessive consumption of processed or charcoaled meats has been linked to a probable increase in the risk of prostate cancer.

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