Einstein Expert Comments on New Prostate Cancer Research
The debate over routine screening for prostate cancer—the most common form of cancer in men outside of skin cancer—has been reactivated by new research showing that deaths from prostate cancer have stopped declining and the incidence of advanced disease has increased.
Some urologists attribute these trends to a reduction in screening generated by guidelines from a federal advisory commission that discouraged routine testing for prostate-specific antigen (PSA). Serge Ginzburg, MD, director of the Prostate Cancer Center at Einstein Healthcare Network, was among those who publicly opposed recommendations issued in 2008 and 2012 by the U.S. Preventive Services Task Forces, an independent volunteer panel of national experts; indeed, he appeared before Congress last year to warn against the consequences.
Dr. Ginzburg told the Congressional committee at the time that PSA screening is “critical,” and largely accounts for what had been the drop in prostate cancer deaths. “Recommending against (PSA testing) is really irresponsible, in my opinion,” he testified.
He’s not, then, surprised by the worrisome trends described in the new research, published May 22 in Cancer, a publication of the American Cancer Society. “That was predicted by the urology community,” he said. “I think the trends are real and are going to get worse” as the consequences for the decline in screening continue to be felt.
In 2008, the commission recommended against screening men over 75 and said evidence was insufficient to decide whether or not to screen younger men. In 2012, it recommended against PSA screening for all men.
Dr. Ginzburg has a more nuanced reaction to the new research than the sorrowful “I told you so,” being voiced by some urologists. Yes, he said, the research results can be attributed in part to the fact that universal PSA testing dramatically declined in the aftermath of the advisory commission’s recommendations. But the increase in advanced disease, for instance, also may be attributable to better diagnostic tools, he said. Cancer that has spread is now more readily detectable than before because of more sophisticated imaging technology—MRIs with high-power magnets, for instance. “We’re seeing fewer people with early prostate cancer and more people with advanced disease,” he said.
The federal commission’s guideline was prompted by the concern that doctors were over-diagnosing patients with non-aggressive prostate cancers by performing unnecessary biopsies and delivering radiation, doing surgery and performing other interventions that exposed patients to unnecessary risk. Dr. Ginzburg said urologists have since “self-corrected,” pursuing more appropriate care such as further non-invasive risk evaluation for patients with elevated PSA or “active surveillance” for patients with low-risk prostate cancer instead of aggressive intervention. “Patients are much less likely to be treated for clinically insignificant prostate cancer which may never catch up to them in their lifetime,” he said.
In addition, Dr. Ginzburg was excited to share that Einstein Urology is among the few early adopters of a safer way to biopsy the prostate—transperineal biopsy, in which the needle is inserted through the skin rather than through the rectum, and significantly reduces the risk of infection, he said. This approach is widespread in Europe and Australia and is only beginning to catch on in the United States. Dr. Ginzburg is among the first in Philadelphia to offer this procedure in the office setting.
The U.S. Preventive Services Task Force amended the 2012 advisory against PSA testing last month, recommending instead that the decision about screening be made on a case-by-case basis by a doctor and patient, based on individual risk determined by age, heredity and race.
About one in nine men will be diagnosed with prostate cancer during his lifetime. Prostate cancer is the second leading cause of cancer death in American men, behind lung cancer. It develops mainly in older men, African American men and men with family history of prostate cancer; six out of 10 cases are diagnosed in men over the age of 65.
The higher incidence of the disease in African American men is of particular concern to Dr. Ginzburg. “African American men are 60 per cent more likely to get prostate cancer, but they’re not being proportionally screened. We can help change that,” he said.
Einstein hosted a special education event for community and religious leaders in April and sponsored a free PSA screening on June 9 as part of Men’s Health Month.