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Last summer, Joe Lowry made an appointment to see a urologist. He would occasionally notice blood in his urine and wanted to get it checked out. His doctor ordered a prostate-specific antigen, or PSA, test to measure a protein in his blood that might indicate prostate cancer — or a number of more benign conditions.
“It came back up a bit,” said Mr. Lowry, 68, an instructional designer who lives in Berkeley, Calif. The biopsy found only a few cancerous cells, “a tiny amount.”
Mr. Lorry was in very little danger, but nobody likes to hear the C-word. “It’s disturbing to think that cancer is growing inside of me,” he said.
But because his brother and friend had both been diagnosed with prostate cancer and had undergone aggressive treatment he’d rather avoid, Mr. Lowry was comfortable with a more conservative approach called active surveillance.
It usually means regular PSA assessments and biopsies, often with MRI scans and other tests, to watch for signs that the cancer may be progressing. He didn’t, so now he can get PSA tests every six months instead of every three.
Research shows that an increasing percentage of men with low-risk prostate cancer are choosing active surveillance, such as Medical guidelines now recommend.
Diagnosis is used to lead directly to powerful treatment. As recently as 2010, about 90 percent of men with low-risk prostate cancer underwent immediate surgery to remove the prostate gland (prostatectomy) or received radiation therapy, sometimes with hormonal therapy.
But between 2014 and 2021, it was a percentage The number of men at risk of developing cancer who chose active surveillance increased to nearly 60 percent from about 27 percent, according to a study using data from the American Urological Association’s National Registry.
“Certain progress, but it’s still not where we need to be,” said Dr. Matthew Kupperberg, a urological oncologist at the University of California, San Francisco, and lead author of the study.
Changing medical practice often takes a frustratingly long time. In the study, 40 percent of men with low-risk prostate cancer were undergoing invasive treatment. Methods vary widely among urological practices.
The percentage of men on active surveillance, Dr. Kupperberg said, “ranges from 0 percent to 100 percent, depending on which urologist you happen to see.” “This is absurd.”
latest results A large British study, which was recently published in the New England Journal of Medicine, provides additional support for monitoring. Researchers followed more than 1,600 men with localized prostate cancer who, from 1999 to 2009, received what they described as active surveillance, prostatectomy or radiation with hormonal therapy.
Over an exceptionally long follow-up averaging 15 years, fewer than 3 percent of the men, whose average age at diagnosis was 62, died of prostate cancer. The differences between the three treatment groups were not statistically significant.
Although cancer in the control group was more likely to metastasize, it did not lead to a higher mortality rate. said Dr. Oliver Sartore, a Mayo Clinic oncologist who specializes in prostate cancer, who wrote An editorial accompanying the study.
“It doesn’t help people live longer,” Dr. Sartore said of the treatment, possibly because of what is known as competing mortality, the possibility of dying from something else first.
Experts caution that men whose prostate-specific antigen (PSA) readings and other test results indicate high-risk tumors, or who have a family history of prostate cancer deaths, fall into a different category.
“The goal of screening is to find aggressive tumors — a small minority, but they kill more men than any other cancer except lung cancer,” said Dr. Kupperberg.
But most prostate cancer grows so slowly, if it grows at all, that other diseases are more likely to be fatal first, especially among older men. During the British study, one in five men died of other causes, mostly cardiovascular or respiratory disease and other types of cancer.
That’s why the guidelines from US Preventive Services Task Force and the American College of Physicians It is not recommended that routine prostate cancer screenings be done for men over the age of 69 or 70, or for men younger than 10 to 15 years of age. (Men ages 55 to 69 are advised to discuss the harms and benefits with their health care providers before deciding to be screened.)
newly revised Guidelines from the American Urological Association Recommend participation in decision-making after age 69, taking into account age, life expectancy, other risk factors, and patients’ preferences.
“If you live long enough, prostate cancer is almost a normal feature of aging,” explained Dr. Kupperberg. “By their 70s or 80s, half of all men will have some cancer cells in their prostate.”
Most of these tumors are considered “indolent,” which means they don’t spread or cause troublesome symptoms.
however, About half of all men over the age of 70 continue to be screened for PSAAccording to a new study in JAMA Network Open. Although they decline testing with age, “they really shouldn’t be screened at that rate,” said lead author Sandhya Kalavacherla, a medical student at the University of California, San Diego.
Even among men over 80, nearly 40 percent were still having routine PSA tests. Dr. Sartore acknowledged that a high PSA reading could spur a series of subsequent tests and treatments, because “cancer” is an emotionally charged term.” He said he still sees patients, whose low-risk cancer response is, “I want it now.”
But the treatment does have significant side effects, which often abate after a year or two but may persist or even worsen. British data showed, for example, that After six months of treatmentUrinary leakage requiring bandages affected nearly half of the men who underwent prostatectomy, compared with 5 percent of those undergoing radiation and 4 percent of those undergoing active surveillance.
After six years, 17 percent of the prostatectomy group still needed dressings; Among those on active surveillance, it was 8 percent, and 4 percent in the radiation group.
Likewise, active control men were more likely to retain erections, although all three groups reported a decline in sexual function with age. 12 years later, Men in the radiation group were twice as likely, at 12 percent, to report fecal leakage as men in the other groups.
The financial costs of unnecessary testing and treatment are also high, an analysis of claims from a large Medicare Advantage program shows. The study, which was recently published in JAMA Network Open, says, I looked at the payments For regular PSA screening and related services for men over the age of 70 who do not have pre-existing prostate problems.
“Initial screening, which is unnecessary, triggers these follow-up services, which are an anxiety-stimulated chain of events,” said David Kim, a University of Chicago health economist and lead author of the study. “The further it progresses, the more difficult it will be to stop it.”
From 2016 to 2018, every dollar spent on PSA testing on men over 70 generated another $6 spent on additional PSA testing, imaging, radiation, and surgery.
Extrapolating from traditional Medicare beneficiaries, Dr. Kim said, Medicare could have spent $46 million on PSA tests for men over 70 and $275 million in follow-up care.
“We need to change incentives, how providers get paid,” he said.
He noted that refusing to compensate them for procedures that receive low recommendations from the US Preventive Services Task Force could mean fewer inappropriate PSA tests and less aggressive treatment in their wake.
Some urologists and oncologists have called for a different kind of transformation label. “Why do we even call it ‘cancer’ in the first place?” Dr. Sartor asked who He argued against the use of the word For small, low-risk tumors of the prostate.
A less scary label — indolent lesions of epithelial origin, or IDLE, was one suggestion — could leave patients less inclined to see test results as fatal and more willing to carefully track a common condition that may never lead to an operating room or focused radiation.
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