Prostate cancer kills 30,000 American men each year. That’s one out of every 40 men. One of every nine men will be diagnosed with it sometime in their lifetime.
Prostate cancer can grow slowly and not cause symptoms in the early stages. That’s why screening is so important. We are here to clear up confusion about who should get tested and when, learn about the value of certain tests, and learn about research happening here at the UVM Medical Center and UVM Cancer Center that aims to improve how risk is determined, among other things.
Listen to an interview with Dr. James Wallace, a radiation oncologist and chief of radiation oncology at the UVM Medical Center, and an associate professor at the Larner College of Medicine at UVM. Or, read the transcript that follows.
Prostate Cancer: Why is the prostate particularly susceptible or vulnerable to cancer?
That’s a great question we don’t exactly know the answer to. We know that all cancers or most cancers occur as we get older, and there is something unique about the prostate gland that tends to grow cancers as we get older. There are various reasons for it. The belief is that there might be some inherent environmental issues such as diet, for example — particularly diet as we’re becoming adolescents and young men — that may have some impact on our likelihood of developing prostate cancer, but we don’t really know the underlying cause.
Is prostate cancer typically higher in African-Americans than Whites?
Yes, there are a number of risk factors that we’re specifically looking at in the research project we’re going to be talking about it in a few minutes, but being African-American definitely increases one’s risk of developing prostate cancer.
The practice for quite a long time was to do PSA tests. What is the frequency in age and other parameters involved?
So, it’s really interesting, PSA was a blood test that was really not developed as a screening tool. It was discovered in a laboratory, found to be associated with prostate cancer and it’s the amount of cancer somebody had in their body. But once people, primarily providers, primary care providers and others found out that it was a test that was associated with prostate cancer, it very rapidly got widely deployed around this country mostly as a screening tool. So, from its discovery in the 1980s to its very wide utilization in the early 1990s it was associated with a significant and rapid increase in diagnosis in prostate cancer.
Fast forward to a few years ago when a federal task force called those practices into question, the use of the PSA test, the frequency age and so forth. Why don’t you describe what they said and what has ensued since then, because there’s not agreement on this.
Yes, it’s an area of a significant amount of controversy. So, the United States Prevention Task Force in 2012 made very clear recommendations about PSA screening, and they were based on a number of studies that had been done prior to 2012. The studies were done because there was clearly a lack of consensus about how we should, or even if we should, screen for prostate cancers. So, we have to think a little bit about why would you or why wouldn’t you screen. One of the advantages, obviously, of screening is that you detect cancer early and it’s more likely to be cured if caught early. But, prostate cancer, and there’s a specific population of men with prostate cancer, have prostate cancers that are so slow to grow that we know if we follow those men without treatment they will never die of their cancer. So, the question you have to ask is, is it worth finding those cancers.
So, in the ’90s and early 2000s we didn’t know the answer. We wanted to find every cancer. What unfortunately happens if you use PSA indiscriminately is men end up getting a biopsy based on an abnormal PSA, even though in the end they do not have cancer. So you’re exposing men to the risk and discomfort of a biopsy, and there’s some risk of the biopsy. In other men, you do the biopsy and you find a cancer and you find out that it’s so small and slow growing that they don’t need treatment anyway. But then you tend to have to go through a significant discussion with the patient saying you’ve got cancer but you don’t need treatment. That’s a very difficult concept for patients to understand.
So, typically, then, you expose them to the risk of treatment with no benefit. For example, I see men from time to time who have these very small, slow growing cancers and I tell them if you don’t get treated, the chance you will die is zero percent over the next 10 years. I can’t get any better than that, but still they have this concern about prostate cancer, as I would, frankly.
So, there were a number of large studies, two large studies specifically, that were done to try to define the role of PSA screening. Both of them took men and assigned them either to a group that got screened routinely – meaning every year to every four years – or a group that did not get screened at all. The results of that were in a way inconclusive in that, sure, we detected more prostate cancers, maybe we found a few that would have been life-threatening, but we exposed lots and lots and lots of men to tests they didn’t need or to treatments and side effects from treatment that probably wouldn’t benefit them. So, that’s what led, in 2012, to the task force saying we should not be screening for prostate cancer.
Where do you come down on that?
That’s really what we’re going to be talking about in a minute I think with the research project, but things have evolved certainly since 2012, and it’s clearly informed my belief about it. I’ll tell you, before 2012, I made my primary care doctor have me get my PSA based not on such great data, but there’s more and more data now. So, for example, the recommendation from 2012 from the task force was based on the studies we talked about a minute ago. People have analyzed the data from these studies and realized that maybe they were misleading. And, since 2012, we at the University of Vermont Medical Center have been very clear with our patients with what we call low-risk prostate cancer, that most of them do best if we don’t treat them. So, therefore, we don’t expose them to the risk of therapy.
So, things have changed over the past six years. We’re not treating men if they don’t need it, as long as we can convince them that they’re fine without that treatment. And we think that there probably is a population of men who can benefit from this screening. And then finally, really the motivation for me personally to think about this, is when we completely abandon screening, while it’s anecdotal, we do see and I see men occasionally in my practice who never were screened and present with very significant widespread and incurable cancer, which is really tough to see and tough for the men to accept, frankly.
You are conducting a clinical trial at the UVM Cancer Center, where you’re trying to really get to a better way of determining risk, as I understand it, and you have kind of an interesting collection of colleagues working on it.
Yes. So, we pulled together a bunch of interested people — ranging from a number of people in our primary care practice, urologists, mathematicians, scientists, biochemists, myself, medical students and research associates — to help us try to figure out the best way to help solve the dilemma about what to do about PSA screening.
Our study is basically twofold. One part is to see if we can take the known risk factors for developing prostate cancer, including, as we discussed before, being African-American, but others including having an elevated PSA at a young age. So, doing one and having that help direct us as well as some underlying genetic risk factors that people might have, including being carriers for the breast cancer genes that people are aware of. Ultimately when the system’s complete, when men see their primary care provider there will be an indicator as to what that man’s risk is in our electronic health record.
So, in a man who is perceived to be at high risk based on information that we already have in their chart, then the primary care provider and the patient can have the conversation about should they be screened for prostate cancer using PSA. And, in fact the task force is going be changing the recommendation. We believe they have a draft recommendation change that men should at least have this informed decision-making process with their primary care provider, and we’re simply extending that and talking about it specifically in men at various levels of risk.
So, men at higher risk we are recommending that they continue to get annual PSA tests, and that is built into their chart. But for men at lower risk, like me, for example, that had a low PSA and had no other significant risk factors, I would get, according to our paradigm, a PSA every four years, which would be often enough to catch the bad cancers but not so often that I’m just getting a test every year that really doesn’t have any benefit.
The second and equally important part of the study is seeing if we can identify something that’s better than a PSA test. So, in addition to simply assigning men to a risk and getting PSA, for a select group of men we’re asking them if they’d be willing to take part in the second part of the study, which is getting samples of their blood periodically and storing that blood so that when our basic scientist researchers at University of Vermont Cancer Center have an idea of a test that might be better than PSA, we have blood saved on men who don’t have prostate cancer now that we know of, but maybe if we use the right test this new test would find it. And if we follow these men over the years — and we hope this study will be a many, many year study — we’ll have blood samples from men as they’re going through the process of developing this prostate cancer over time.
So, we are specifically, at this point, looking for volunteers who’d be willing to take part in that. We call it the Biomarker Study.
How would they find out more information about participating?
So, a couple of ways. The primary care offices within the University of Vermont Medical Center primary care networks — that includes family medicine and primary care in the internal medicine practice — should have information. And then people that are interested specifically can call our research coordinator directly. Her telephone number is 802-656-9924. She can give you all the information that you need about what the next steps might be if you’re interested in taking part in the Biomarker Study.
Is it unusual to have that combination of expertise in a study?
Well, it’s something that we thought was unique about our circumstance here in Burlington and in Chittenden County that we do have very active primary care providers interested in research. And, we have the researchers in the medical school who are interested in doing the basic research. And, there are those of us who take care of prostate cancer as kind of intermediaries between the two. So, it is an area of increased interest among lots of researchers, including cancer center researchers here, to figure out how we can get involved with our primary care providers and get more patients involved in research. Not so much once they already have cancer but maybe there are screening and prevention studies we can get people involved in.
Radiation oncology: Is there something new about what’s going on? There always seem to be advances in technology.
So, I think there’s a big focus on how we can be more efficient with how we deliver radiation. Our technologies have changed over the past few years so that we can be incredibly precise as to where the radiation beams go, sparing normal tissues from radiation. So, with that level of precision, we’re now trying much more rapid treatment schedules. Historically, because there are potential risks of exposing people to high doses of radiation, we’d give very small doses of radiation each day over many, many weeks, knowing that the normal tissues could tolerate that reasonably well.
But, now, with the new techniques we have — and we know that we can do this safely based on experience at other institutions — we’re going to be opening a trial that will take essentially nine weeks of treatment and see if we can deliver it in five days. We’re going to be taking part in a national collaborative approach to really study this and make sure that it’s safe and effective.
Well, that is really a big, big change from where you were just a few years ago.
Big change, and again, based on technology as well as our better understanding of the biology, we call it the radiobiology, how we understand how radiation works and kills cancer.