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HealthActive surveillance still likely the best approach to low-risk prostate cancer

Much confusion has been generated among medical professionals and men diagnosed with low-risk prostate cancer by a recent radical rethink on treatment guidelines published by the US National Comprehensive Cancer Network. The NCCN is a well-respected body that for years has supported the generally accepted approach that the best treatment for men diagnosed with low-risk prostate cancer is to do nothing — or, rather, to monitor the progress of the disease through “active surveillance”. Now...
Jonathan GornallDecember 12, 202111 min
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Much confusion has been generated among medical professionals and men diagnosed with low-risk prostate cancer by a recent radical rethink on treatment guidelines published by the US National Comprehensive Cancer Network.
The NCCN is a well-respected body that for years has supported the generally accepted approach that the best treatment for men diagnosed with low-risk prostate cancer is to do nothing — or, rather, to monitor the progress of the disease through “active surveillance”.
Now the NCCN has issued new guidelines turning that approach on its head. It is  recommending that both radiation therapy and surgery should be considered as equally viable options for the treatment of low-risk prostate cancer.
This has provoked a storm of comments from urologists on Twitter. Words typifying the responses included “terrible”, “baffled”, “ludicrous”, “off the rails”, and “a huge setback” and “frankly a disgrace.”
The controversy stems from the fact that the only available treatments for prostate cancer — radiation and/or surgery — can frequently cause more harm and inflict more damage on a patient’s quality of life than the cancer itself.
Prostate cancer is a fact of life for nearly all men, and a product chiefly of age — live long enough, and you are almost certain to get it.
It is the second-most common cancer and the fifth leading cause of cancer death in men worldwide. It is not attributable to any known risk factors, preventable or otherwise, other than age — the peak age for diagnosis is between 75 and 79.
But more men will die with prostate cancer, than from it. Something else is much more likely to kill them, in other words, before prostate cancer gets a chance to do so.
And rates of incidence and death vary widely around the world. Quite why, remains uncertain, but contributory factors doubtless include lifestyle and genetic predisposition, not to mention approaches to screening and treatment.
The good news for men in the Gulf states is that they are less likely than their peers elsewhere both to contract and to die of prostate cancer.
Globally, according to figures from 2018, 30 men in every 100,000 will contract the disease every year. In Sweden, the US and the UK, however, the incidence rate jumps to 119, 98 and 73 respectively, while the rate in the Gulf states is less than half the global average: 14.5 in Kuwait, 13.5 in Bahrain, 13.2 in Qatar, 10.2 in Oman, 10 in the UAE and only 9.5 in Saudi Arabia.
Similarly, the death rates in these countries are also lower than elsewhere. Globally, 13 men out of every 100,000 with prostate cancer die every year. Surprisingly, Sweden is the worst performer, with a death rate of 17.8 per 100,000.
By contrast, the death rates in the GCC states are much lower than the global average: 6.5 in Bahrain, 6.3 in Oman, 6 in Qatar, 5.6 in the UAE, 4.8 in Saudi Arabia and 3 in Kuwait.
Amid the confusion surrounding the controversial guidance issued by the NCCN, there is an important point to be drawn from these statistics by urologists practising in many countries in the Middle East.
While the risks of contracting and dying from the disease are much lower than in the US, for example, where the NCCN operates, any of the downsides presented by radiation therapy and surgery remain the same wherever one lives.
A key problem with the treatment of prostate cancer has always been that, unlike with breast and cervical cancer, for which highly effective screenings programs exist, it is difficult to detect and diagnose in time for treatment to be effective. At first, and often for a long time, prostate cancer is asymptomatic. When symptoms do finally appear, in many cases the cancer is too advanced for successful treatment.
The prostate is a small gland through which the urethra passes, carrying urine from the bladder. The gland grows in size with age, which is why many men experience difficulty urinating as they grow older. This harmless, if annoying, condition is known as benign prostatic hyperplasia.
In some advanced cases prostate cancer can cause the same problem, which is why a regular physical examination of the gland in older men is a first line of defense against the disease. However, the  detection of a possibly swollen prostate is alone insufficient evidence of a developing cancer. Equally, the absence of swelling is not a clear indication that all is well.
This is why the discovery in the late 1970s of a simple blood test to detect prostate cancer was seen as such a breakthrough. It works by measuring the level in a man’s blood of a protein called PSA, or prostate-specific antigen. Although PSA is produced by normal as well as malignant cells in the prostate, it was found that, in general, the higher the PSA level, the more likely that cancer was present.
But, unlike screening for breast or cervical cancer, screening for PSA is no slam-dunk.
For one thing, PSA levels fluctuate normally, so a series of tests offers a better chance of accurate diagnosis. A failure to take this into account is responsible  for both false negative and false positive testing. The consequences of a false negative — a failure to detect the presence of prostate cancer — can lead to death, but in many cases is unlikely to have any consequences.
“A major harm of PSA screening,” as a paper published last year in the journal The Medical Clinics of North America put it, “is over-diagnosis — the diagnosis of indolent, slow-growing prostate cancer that would otherwise not be diagnosed during the man’s lifetime.”
Over-diagnosis, of course, leads to over-treatment of low-risk prostate cancer with surgery and radiation, which has “no, or almost no, benefit in terms of mortality reduction but leads to important and persistent side-effects, most notably, urinary and erectile dysfunction”.
Likewise, a false positive PSA test, if acted upon aggressively, can lead patients down the same harrowing path.
All of which explains why active surveillance has become the preferred approach in such cases — and, despite the controversial new advice from the NCCN, is likely to remain so.

Jonathan Gornall

Jonathan Gornall is a freelance British journalist who has lived and worked in the Middle East and is now based in the UK.

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