Researchers: Stop castrating men with prostate cancer –
There has been a great controversy in the last few years regarding the “over treatment” of prostate cancer. Certainly castration would be considered by some a controversial “over treatment.”
Let’s get right to the research. In November 2018, a team of urologists from VA Ann Arbor Healthcare System and the University of Michigan wrote this in the journal Implementation science. (1)
“Many men with prostate cancer are castrated with long-acting injectable drugs (androgen deprivation). Although some patients benefit, it is also used in patients who have little or nothing to gain, such as men with localized prostate cancer. The best ways to stop, or de-implement, low value cancer care are unknown. A significant scientific and clinical knowledge gap remains in prioritizing which barriers to stopping castration in low value settings need to be targeted for effective de-implementation.”
The problem is what is obviously stated above, “The best ways to stop, or de-implement, low value cancer care are unknown.”
For the man with prostate cancer, his oncologists will discuss and may recommend “Hormone therapy.” This is also called androgen deprivation therapy (ADT) or androgen suppression therapy.”
The patients will be told that this treatment is being initiated to reduce his circulating levels of androgens or testosterone and dihydrotestosterone (DHT). This is necessary to stop these hormones from stimulating prostate cancer cells growth.
It should be pointed out this treatment is not considered a “cure,” for prostate cancer, it is part of a multi-pronged program against the disease.
Should prostate cancer be treated this aggressively?
The above research calls on a 2006 study from the Journal of the National Cancer Institute (2) from the University of Texas. This study from 12 years echo’s the same concerns of November 2018 study.
“The use of androgen deprivation therapy for prostate cancer has been increasing, even in settings for which there is weak or no evidence of efficacy. This pattern suggests that factors other than the typical patient and tumor characteristics may be driving its use. “
What was that factor determining the use of androgen deprivation? The urologist. “Which urologist a patient sees may be more important in determining whether they will receive androgen deprivation therapy.”
In other words, the urologist picked the treatment regardless of the individual need of the patient.
In 2010, a study reported in the New England Journal of Medicine (3), all cited in the above research suggets that there was a decline in the use androgen deprivation therapy, not because the treatment was at question, but because Medicare guidelines stopped covering it for men who did not need it.
Yet the inappropriate use of androgen deprivation therapy remains documented in the medical literature today.
“The best ways to stop, or de-implement, low value cancer care are unknown.”
The undisputed fact is that there is a need in the medical community to seek out and aggressively treat prostate cancer. You may be thinking to yourself, what is wrong with that? There is nothing wrong with that for patients who need aggressive care. Not all prostate cancer patients NEED aggressive care.
Eyes on the PSA as the start of over treatment with low value cart
Screening programs for prostate cancer based on the determination of serum prostate specific antigen (PSA) has led to overdiagnosis, and consequently overtreatment of Prostate cancer. This point, as made in the in the July/August 2017 edition of the medical publication Semergen (4), published in Spain, brings to light the question of how men with prostate cancer are treated, and if they should be “aggressively” treated.
From this study, we also learn that a percentage of men diagnosed with prostate cancer have a tumor that will not progress, or do so slowly (overdiagnosis or pseudo-disease). This overdiagnosis rate ranges from 17-50%.
This study also suggests that early detection or opportunistic screening involves the pursuit of individual cases being initiated by the doctor or the patient. In the case of a patient who requests a prostate specific antigen from their general practitioner, a number of issues on overdiagnosis, over-treatment and possible damage from the biopsy, should be explained to him. With data from randomized studies on prostate specific antigen and prostate cancer screening, population screening is not recommended by any urological society.
Earlier in 2017, a new study from researchers at the University of Michigan published in the journal Health Affairs (5) confirmed that the overall rate of men receiving treatment for prostate cancer declined 42 percent. This because national guidelines now recommend against routine prostate cancer screening and patients and doctors are beginning to understand that there is an overtreatment of prostate cancer occurring.
The researchers say the decline does reflect efforts to decrease overdiagnosis and overtreatment. This may be preventing some unnecessary treatments. Overtreatments can have long-term impacts on quality of life, while still providing life-saving care to patients who need it.
The Michigan researchers noted: “Some prostate cancers are so slow-growing that data suggests the risks of treatment may outweigh the benefits.” Watchful waiting or active surveillance (which involves monitoring patients without delivering treatment) are better options, especially for those patients with low-risk disease or limited life expectancy. By monitoring these patients, urologists can identify when treatment may become necessary.
Prostate cancer, like all cancers is a complex disorder that affects each patient differently. Some patients do require an aggressive approach, some patients not. Our program emphasizes the concept of Thriving While Surviving. We strive to transform cancer from an acute disease into more of a chronic illness, one that can be lived with for many months or even years. Some of our patients have greatly outlived their life expectancy by even two or three-fold. Furthermore, most are able to continue with a productive and fulfilling life.
1 Skolarus TA, Hawley ST, Wittmann DA, Forman J, Metreger T, Sparks JB, Zhu K, Caram ME, Hollenbeck BK, Makarov DV, Leppert JT. De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT). Implementation Science. 2018 Dec;13(1):144.
2. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Determinants of androgen deprivation therapy use for prostate cancer: role of the urologist. Journal of the National Cancer Institute. 2006 Jun 21;98(12):839-45.
3. Shahinian VB, Kuo YF, Gilbert SM. Reimbursement policy and androgen-deprivation therapy for prostate cancer. New England Journal of Medicine. 2010 Nov 4;363(19):1822-32.
4 Jalón MA, Escaf BS, Viña AL, Jalón MM. Current aspects of prostate cancer screening. Semergen. 2016 Aug.
5 Tudor Borza, Samuel R. Kaufman, Vahakn B. Shahinian, Phyllis Yan, David C. Miller, Ted A. Skolarus, Brent K. Hollenbeck. Sharp Decline In Prostate Cancer Treatment Among Men In The General Population, But Not Among Diagnosed Men. Health Affairs, 2017; 36 (1): 108 DOI: 10.1377/hlthaff.2016.0739
6 Prostate cancer treatment rates drop, reflecting change in screening recommendations University of Michigan press release January 8, 2017