Howard Waage ---- Editor
Our monthly meeting will be in the Bennett & Suzy Katz Cancer Resource Center on the 1st Floor of the two-story redwood Education Building behind Santa Cruz Dominican Hospital.
It is the last Tuesday each month, so this month that is November 24th, 2009 at 7:00 PM. For more information, please call - The Bennett and Suzy Katz Cancer Resource Center at Dominican Hospital (831) 462-7770 .
By Gina Kolata
October 21, 2009 - The American Cancer Society, which has long been a staunch defender of most cancer screening, is now saying that the benefits of detecting many cancers, especially breast and prostate, have been overstated.
It is quietly working on a message, to put on its Web site early next year, to emphasize that screening for breast and prostate cancer and certain other cancers can come with a real risk of overtreating many small cancers while missing cancers that are deadly. “We don’t want people to panic,” said Dr. Otis Brawley, chief medical officer of the cancer society. “But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”
Prostate cancer screening has long been problematic. The cancer society, which with more than two million volunteers is one of the nation’s largest voluntary health agencies, does not advocate testing for all men. And many researchers point out that the PSA prostate cancer screening test has not been shown to prevent prostate cancer deaths. There has been much less public debate about mammograms. Studies from the 1960s to the 1980s found that they reduced the death rate from breast cancer by up to 20 percent.
The cancer society’s decision to reconsider its message about the risks as well as potential benefits of screening was spurred in part by an analysis published in The Journal of the American Medical Association, Dr. Brawley said.
In it, researchers report a 40 percent increase in breast cancer diagnoses and a near doubling of early stage cancers, but just a 10 percent decline in cancers that have spread beyond the breast to the lymph nodes or elsewhere in the body. With prostate cancer, the situation is similar, the researchers report.
If breast and prostate cancer screening really fulfilled their promise, the researchers note, cancers that once were found late, when they were often incurable, would now be found early, when they could be cured. A large increase in early cancers would be balanced by a commensurate decline in late-stage cancers. That is what happened with screening for colon and cervical cancers. But not with breast and prostate cancer.
Still, the researchers and others say, they do not think all screening will — or should — go away. Instead, they say that when people make a decision about being screened, they should understand what is known about the risks and benefits. For now, those risks are not emphasized in the cancer society’s mammogram message which states that a mammogram is “one of the best things a woman can do to protect her health.”
Dr. Brawley says mammograms can prevent some cancer deaths. However, he says, “If a woman says, ‘I don’t want it,’ I would not think badly of her but I would like her to get it.” But some, like Colin Begg, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York, worry that the increased discussion of screening’s risks is going to confuse the public and make people turn away from screening, mammography in particular. “I am concerned that the complex view of a changing landscape will be distilled by the public into yet another ‘screening does not work’ headline,” Dr. Begg said. “The fact that population screening is no panacea does not mean that it is useless,” he added.
The new analysis — by Dr. Laura Esserman, a professor of surgery and radiology at the University of California, San Francisco, and director of the Carol Frank Buck Breast Care Center there, and Dr. Ian Thompson, professor and chairman of the department of urology at The University of Texas Health Science Center, San Antonio — finds that prostate cancer screening and breast cancer screening are not so different.
Both have a problem that runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone. That has led to a huge increase in cancer diagnoses because, without screening, those innocuous cancers would go undetected.
At the same time, both screening tests are not making much of a dent in the number of cancers that are deadly. That may be because many lethal breast cancers grow so fast they spring up between mammograms. And the deadly prostate ones have already spread at the time of cancer screening. The dilemma for breast and prostate screening is that it is not usually clear which tumors need aggressive treatment and which can be left alone. And one reason that is not clear, some say, is that studying it has not been much of a priority.
“The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” Dr. Brawley said. “And we never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’”
The very idea that some cancers are not dangerous and some might actually go away on their own can be hard to swallow, researchers say. “It is so counterintuitive that it raises debate every time it comes up and every time it has been observed,” said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health.
It was first raised as a theoretical possibility in the 1970s, Dr. Kramer said. Then it was documented in a rare pediatric cancer, but was dismissed as something peculiar to that cancer. Then it was discovered in common cancers as well, but it is still not always accepted or appreciated, he said.
But finding those insignificant cancers is the reason the breast and prostate cancer rates soared when screening was introduced, Dr. Kramer said. And those cancers, he said, are the reason screening has the problem called overdiagnosis — labeling innocuous tumors cancer and treating them as though they could be lethal when in fact they are not dangerous. “Overdiagnosis is pure, unadulterated harm,” he said.
Dr. Peter Albertsen, chief and program director of the urology division at the University of Connecticut Health Center, said that had not been an easy message to get across. “Politically, it’s almost unacceptable,” Dr. Albertsen said. “If you question overdiagnosis in breast cancer, you are against women. If you question overdiagnosis in prostate cancer, you are against men.”
Dr. Esserman hopes that as research continues on how to advance beyond screening, distinguishing innocuous tumors from dangerous ones, people will be more realistic about what screening can do. “Someone may say, ‘I don’t want to be screened’ ” she said. “Another person may say, ‘Of course I want to be screened.’ Just like everything in medicine, there is no free lunch. For every intervention, there are complications and problems.” Source: http://www.nytimes.com/2009/10/21/health/21cancer.html?hp
Atlanta – October 21, 2009 – “Today’s New York Times article ‘In Shift, Cancer Society Has Concerns on Screening’ indicates that the American Cancer Society is changing its guidance on cancer screening to emphasize the risk of overtreatment from screening for breast, prostate, and other cancers…..
“Since 1997 the American Cancer Society has recommended that men talk to their doctor and make an informed decision about whether or not prostate cancer early detection testing is right for them. This recommendation also still stands. “Cancer is a very complex and complicated disease. The American Cancer Society makes evidence-based cancer screening recommendations, and strives to provide clear messages about cancer screening to patients and doctors. Our guidelines are constantly under review to evaluate them as new evidence becomes available. Simple messages are not always possible, and over-simplifying them can in fact do a disservice to the very people we serve.”
The American Cancer Society combines an unyielding passion with nearly a century of experience to save lives and end suffering from cancer. As a global grassroots force of more than three million volunteers, we fight for every birthday threatened by every cancer in every community. We save lives by helping people stay well by preventing cancer or detecting it early; helping people get well by being there for them during and after a cancer diagnosis; by finding cures through investment in groundbreaking discovery; and by fighting back by rallying lawmakers to pass laws to defeat cancer and by rallying communities worldwide to join the fight. As the nation’s largest non-governmental investor in cancer research, contributing about $3.4 billion, we turn what we know about cancer into what we do. As a result, more than 11 million people in America who have had cancer and countless more who have avoided it will be celebrating birthdays this year. To learn more about us or to get help, call us anytime, day or night, at 1-800-227-2345 or visit cancer.org.
Since the introduction of prostate-specific antigen (PSA) testing, prostate cancer is being detected and treated earlier, before it can spread to other tissues. The earlier prostate cancer is detected, the more easily it can be treated.
Us TOO International Prostate Cancer Education & Support Network recommends that men have annual prostate examinations, which should include both a PSA blood test AND a digital rectal examination (DRE), starting at the following ages:
--- By age 40 if you are an African American man, or have a family history of prostate cancer (either are considered high-risk). No later than age 45 for all other men.
Moreover,
--- It is extremely important to "KNOW YOUR PSA." Keep a record of the exact numbers, not just that it is "in the normal range." Your first PSA blood test establishes your ‘baseline’ PSA score.
--- By tracking your PSA from year to year, you will know if it has increased too much since last year. A rise in PSA levels of 0.75 ng/mL or more within one year may require further investigation by your doctor. The rate of change in your PSA level can be a more significant sign of disease than the actual PSA level.
--- Us TOO believes that annual testing is so important that men should make it a calendar event such as your birthday, Father’s Day or during September, which is Prostate Cancer Awareness Month.
--- Us TOO believes that following these recommendations will help detect prostate cancer earlier, improve the quality of life of diagnosed patients, and decrease the number of deaths caused by prostate cancer.
--- Us TOO believes that the earlier the disease is detected, the more easily and effectively it can be treated.
--- Us TOO also believes that the benefits of early detection and treatment outweigh the cost and inconvenience of occasional false positives that result in biopsies of healthy tissue. Those benefits are in the form of reduced overall cost and increased effectiveness of treating the disease.
Prostate-specific antigen is a substance that is normally produced by the prostate gland and a small amount of PSA can usually be detected in the blood. However, if the prostate begins to make too much PSA, it could be a sign of an enlarged prostate (also known as BPH – benign prostatic hyperplasia), inflammation, or cancer. The doctor will draw blood and measure the PSA level. Although the exact definition of “normal” PSA level continues to be debated, Us TOO suggests that the following ranges be used:
--- Establish a baseline by age 40 if you are African American or have a family history of prostate cancer, but no later than age 45 for all other men.
--- Track your PSA score over time. PSA doubling time and PSA velocity are currently thought to be better for telling how aggressive a cancer is than knowing your current PSA number. We are all unique – PSA levels vary from person to person.
Source: http://www.ustoo.org/Early_Detection.asp#Recommendations
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Stan Rosenfeld, Prostate Cancer Survivor and Patient Advocate/Educator
Cancer Causes Control. 2008 Mar;19(2):175-81.
Fred Hutchinson Cancer Research Center, Seattle, WA. OBJECTIVE: To quantify the plausible contribution of prostate-specific antigen (PSA) screening to the nearly 30% decline in the US prostate cancer mortality rate observed during the 1990s. METHODS: Two mathematical modeling teams of the US National Cancer Institute's Cancer Intervention and Surveillance Modeling Network independently projected disease mortality in the absence and presence of PSA screening. Both teams relied on Surveillance, Epidemiology, and End Results (SEER) registry data for disease incidence, used common estimates of PSA screening rates, and assumed that screening, by shifting disease from distant to local-regional clinical stage, confers a corresponding improvement in disease-specific survival. RESULTS: The teams projected similar mortality increases in the absence of screening and decreases in the presence of screening after 1985. By 2000, the models projected that 45% (Fred Hutchinson Cancer Research Center) to 70% (University of Michigan) of the observed decline in prostate cancer mortality could be plausibly attributed to the stage shift induced by screening.
CONCLUSIONS: PSA screening may account for much, but not all, of the observed drop in prostate cancer mortality. Other factors, such as changing treatment practices, may also have played a role in improving prostate cancer outcomes.
PMID: 18027095 [PubMed - indexed for MEDLINE]
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The Santa Cruz County Prostate Cancer Support Group does not endorse any provider, organization, product or individual. All medical decisions should be made with the advice and consultation of medical professionals.
Many THANKS to the American Cancer Society for assisting with the printing and mailing of this newsletter and the Katz Cancer Resource Center for allowing us to use their facility.