Prostate Cancer Part II

By John D. Hastings, M.D.

Sport Aviation, April 1998

An article regarding prostate cancer in the December issue of Sport Aviation prompted numerous responses, and I felt the comments should be shared with our members. My intention was to share my personal experience with a difficult problem rather than to endorse any one treatment. Members emphasized the controversy over screening for prostate cancer and the complexity of choosing treatment alternatives once disease is found. For broader understanding of this disease, we revisit this topic.

A member wrote:

Dear EAA,

As a senior AME and member of your Pilot Advocate Program, I am always pleased to see medical articles in Sport Aviation. However, Dr. Hastings’ article in your December issue over-simplifies a very complex issue - that of the value of screening for prostate cancer. Given the limited benefits of this procedure and possible serious complications from surgery, the real question is "Is it worth it?"

Since Dr. Hastings drafted this article, it should be mentioned that the American Cancer Society no longer recommends "an annual PSA beyond age 50."

They do, however, recommend that "men over 50 discuss the need "for PSA testing’." Similarly, the most objective group to look at the screening test (the U.S. Preventive Services Task Force) in their 1996 "Guide to Clinical Preventive Services" states that screening for prostate cancer is not recommended. It is the feeling of this objective body that the potential risks of screening (and the procedures which follow) are greater than the potential benefits. There are several studies of males over 50 years of age that have found that treatment is actually more harmful than simply watchful waiting.

Operative mortality is perhaps one out of every 200 patients. Impotence is nearly universal and permanent incontinence requiring the use of a device ranges up to 30%. It should be noted, however, that younger patients undergoing surgery do have a lower complication rate. Radiation therapy has its own set of problems. The figures there are not greatly different, except for lower incidence of incontinence.

In addition to these data is the fact that no study has shown conclusively that screening for prostate cancer leads to increased survival. What is the final word? There is no final word. The utility, the risks, and the benefits of prostate cancer screening must be discussed between the individual patient and his physician. To simply say that every male over 50 should be screened is simply not correct.

John W. Beasley, M.D., EAA 198340

In 1998 some 400,000 men will be diagnosed with prostate cancer, the most common cancer in men (after lung cancer) and the second most common cause of male cancer deaths. Gland-confined cancer often causes no symptoms; spread beyond the prostate is present in 40% at time of diagnosis. PSA testing detects twice as many cancers as digital rectal exam.

The American Cancer Society and Dr. Beasley recommend discussion of prostate screening at age 50. In a course offered by the American College of Preventive Medicine last summer, discussion of screening by representatives of the U.S. Preventive Services Task Force sparked heated debate. A decision to screen everyone includes issues including cost; the individual’s best interest may not be of prime importance. The American Urological Association and American College of Radiology recommend annual screening.

Detractors of PSA-screening cite lack of evidence that early detection saves lives, possible unnecessary treatment of insignificant cancers, false positive tests, and cost. Those advocating screening cite lack of proof that screening does not save lives, note that 85% of prostate cancer treated today are clinically significant, and claim that early detection can cure localized disease.

Indeed, there is no final word, and screening for prostate cancer is an individual decision. Two government studies in progress, PIVOT (Prostate Cancer Intervention vs. Observation Trial), and PCLO (Prostate, Lung, Colon, and Ovarian Cancer) study, will provide further data. Screening was right for me. My choice of treatment (or no treatment) remained.

Once cancer is found, one must consider treatment alternative. For some continues observation might be appropriate. Men with life expectancy under ten years, those over 70 with low grade tumors, those with localized disease who choose to wait, and those whose cancer has spread but with no symptoms might choose this alternative. Waiting costs nothing and has no side effects.

Disadvantages of observation include cancer growth, change to a higher grade malignancy, and studies indicating spread beyond the gland will occur in nearly half over ten years.

External beam radiation therapy (a beam directed at the prostate from the outside) is another option. This can be used in all stages of the disease (localized, spread, and recurrent). Those fearing surgery and its complications might choose radiation, and outcome is similar to that of radical surgery. Disadvantages include inability to stage the cancer, difficulty in assessing cure, and complications including rectal irritation and urinary difficulty.

Radioactive seed implantation (brachytherapy) is an alternative. Candidates include those with life expectancy of ten years, those fearing surgery, older men with poor surgical risk, and those with locally advanced disease.

Surgery is a third option. Candidates include those with life expectancy of ten years and organ confined disease. The disease may be cured, though cure is not assured. Disadvantages include the major nature of surgery and complications including impotence and incontinence. Erectile dysfunction of variable degree occurs in 25-75% of cases. Urinary incontinence may occur in 5-30%, the younger patients faring better.

I endorse no one treatment for prostate cancer. Dr. Beasley is correct in stating that prostate cancer screening (and its treatment) warrants thorough discussion between patient and physician.

(Dr. Hastings, EAA 451228, is Chairman of the EAA Aeromedical Advisory Council.)