Australasian Science: Australia's authority on science since 1938

Why No Man Should Take a PSA Blood Test for Early Stage Prostate Cancer Without Reading This

By Ian Haines

Men with early-stage abnormalities of the prostate who are monitored for any progression of the cancer live just as long as men who opted for complete removal of the prostate and now live with the immediate consequences.

From the 1980s, when prostate screening became available, many men over 40 without symptoms were diagnosed with early stage prostate cancer. However, most prostate cancers take decades to reveal themselves, and most men will die with, but not from, prostate cancer.

Autopsy studies reveal prostate cancer in up to 40% of men in their forties and 65% in their sixties, but only 3–4% of Australian men actually die of prostate cancer at a median age of 82. So why would any man agree to a PSA test and then a biopsy and radical treatment?

Hard evidence against such drastic steps is strong. In the UK’s ProtecT trial, three groups of men experienced either surgical removal of the prostate (553 men), radiation treatment (545 men) or active monitoring (545 men). After 10 years, the total number of deaths due to any cause was 55, 55 and 59, respectively.

Although surgery delayed the development of secondary cancers in a small number of men, the number of deaths definitively attributable to prostate cancer in each group was low – only three, four and seven deaths, respectively – so the odds of dying specifically from prostate cancer in the first 10 years is in the order of 1%, with no survival advantage for treatment.

In a second PIVOT study from the US, two groups of men experienced either surgical removal of the prostate (364 men) or active monitoring (367 men). After nearly 20 years of follow-up, the number of deaths due to any cause was 223 and 245, respectively.

Surgery did not prevent death any more than active monitoring. Strikingly, the number of deaths definitively attributable to prostate cancer in the two groups was only 18 and 22, respectively, meaning that the odds of dying specifically from prostate cancer in the first 20 years after a cancer diagnosis from a PSA test was about 5% for the surgical group and 6% for the active monitoring group.

Survival from prostate cancer is so high it’s not a question of deciding which treatment is best, but whether any early radical treatment is required at all. The current position has been clearly articulated by the Chief Medical Officer of the American Cancer Society, Dr Otis Brawley, who points out that aggressive PSA screening and treatment has resulted in more than one million American men undergoing needless treatment.

Patients who have undergone surgery are also four times more likely to require absorbent pads for incontinence and three times more likely to have erectile dysfunction. These are not issues that are routinely highlighted.

In 2017, prostate cancer was estimated by the Australian Institute of Health and Welfare to be the most commonly diagnosed cancer, but Australian men are not having their options for testing and treatment of early prostate cancer properly explained, perhaps because urologists, who have a huge financial conflict of interest, are the gatekeepers and often the sole medical advisers about treatment. It seems a scandal.

For those who choose investigation and treatment there is additional data. Robot-assisted prostatectomy has been used over the past 16 years and is now used for 60% of prostatectomies, but recent Australian research published in the Lancet found it no more effective than open surgery for urinary control, erectile function and cancer outcomes. No benefits, but vast extra expense.

Another recently published Australian study contradicts the common misconception of surgeons that side-effects associated with radiation therapy are worse than surgery. In fact it was the surgical side-effects that caused the most regret.

The key to reducing decision-regret is allowing patients who want treatment to make the most informed choice possible. The first step must be to educate doctors so they can provide full disclosure to any patient of the results of these trials.

Similar to countless past treatments that evidence has made redundant – such as lobotomy for mental illness and stomach surgery for ulcers – it’s now clear that radical surgery removing the prostate should not be the go-to option.

Dr Ian Haines is a medical oncologist and Adjunct Clinical Associate Professor of Medicine at Monash University.