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What will study reveal about prostate cancer?

Shahar Madjar, MD

Goteborg. The second largest city in Sweden. Population 590,000. It lies along the west coast of the country. Despite its northern location, the temperature is mild throughout the year. It is known for its world’s largest cinnamon buns served at Cafe Husaren and for its thrilling rides at Liseberg Amusement Park. It’s also famous for one of the longest lasting studies on prostate cancer screening.

Prostate cancer is common. According to the Center for Disease Control, 13 out of 100 Americans will be diagnosed with prostate cancer during their lifetime, and 2-3 out of 100 Americans will die from the disease. What if doctors could identify the disease and treat it early — could they save lives?

Prostate cancer is unique: like other cancers, it can metastasize to other organs and lead to death, but its course is usually protracted and most men diagnosed with prostate cancer will die with it, not from it.

You see, as men (and women) get old, they accrue medical conditions the way an old car tends to accrue mechanical, electrical, and body problems. Different parts wear and tear at different rates. The engine runs less efficiently. Pumps and pipes fall apart. Rust takes over the body. Finally, giving clicking, ticking, squeaking noises of subdued protest, it finally stops, for ever.

As men get older, a similar process takes place. Different body parts deteriorate at different rates. The heart pumps blood with lesser efficiency, the arteries become narrow and stiff, the lungs can no longer deliver oxygen the way they did at a younger age, and the mind, too, becomes a bit, or much more sluggish. At the same time, as the body ages, cancer may also present itself. And so, toward the end of life, much as in an old car, a variety of processes compete among themselves as if they were asking, “Which one of us will deal the final blow?”

Prostate cancer is typically diagnosed in older men when other medical conditions are already present. Prostate cancer is typically a slow process. And so, as I have mentioned before, most patients diagnosed with prostate cancer, will die of other medical problems, or of old age. And still prostate cancer is the second leading cause of cancer death in American men.

Prostate cancer is silent at its initial phases. The great majority of men with prostate cancer have no alarming symptoms — they are asymptomatic, or have lower urinary symptoms that are typical of older age and are usually caused by benign enlargement of the prostate (rather than malignant disease, or cancer). Therefore, if the goal is early detection, doctors and public health specialists would have to screen for the disease. The word “screening” means searching for a disease using tests and medical procedures in people who have no symptoms.

The most widely used test to screen for prostate cancer is a blood test called PSA which stands for Prostate Specific Antigen. PSA is a protein made exclusively in the prostate. That’s why it is called prostate specific. The test measures the amount of PSA in the blood. The higher the levels of PSA, the more likely a man has prostate cancer.

The problem is this: although PSA is specific to the prostate, it isn’t specific to prostate cancer! In other words, other conditions–non-cancerous conditions–can also cause an increase in PSA levels. One example is Benign Prostatic Hyperplasia (BPH) in which the prostate becomes larger with aging. And as the prostate gets bigger, it produces more PSA. Another benign condition in which PSA levels may increase is inflammation and infection of the prostate called prostatitis. In summary, elevated PSA may be a sign of prostate cancer, but it may also be a sign of other non-malignant, benign conditions.

What are we talking about when we are talking about prostate cancer: we are talking about a prevalent disease that is potentially lethal, but one where most patients will die with prostate cancer rather than from it. And we are also talking about a screening test that is an imperfect tool where a positive test may or may not indicate a serious, potentially life-threatening cancerous disease.

Does screening for prostate cancer save life? And at what cost? The Swedish study from Göteborg provided some answers. I will give you the details in my next article.

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