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Prostate cancer: ‘Over diagnosis’ can cause more harm than good

Prostate cancer

In prostate cancer awareness month, men – especially if they are over 50 – are encouraged to get themselves tested for this disease. But, says a leading oncologist, more needs to be done to counsel patients upfront about the pros and cons of prostate cancer screening and risks of over-diagnosis.

Movember is an international movement to highlight the issues around prostate and testicular cancer in men. While this is a good thing, Dr David Eedes, Clinical Oncology Advisor at the Independent Clinical Oncology Network (ICON), has cautioned that the complexity of getting yourself tested for prostate cancer is often lost in the competition to sport the most impressive fuzz on the upper lip. This diverts attention away from a proper consideration of the pros and cons of screening – including the risk of over diagnosis.

“Increased screening and earlier detection of prostate cancer has brought with it a new set of problems when it comes to the successful management of the disease,” says Dr Eedes.

Prostate cancer is still the second-most diagnosed cancer in men and the third-most common cause of cancer deaths worldwide, so it is no surprise that considerable resources are used to raise awareness about the disease and encourage men – especially if they are over 50 – to look at the benefits of getting themselves screened. But, says Dr Eedes, as there is controversy as to whether generalised screening of men actually reduces the risk of dying of this disease, the harms of screening also need to be considered.

“Generalised screening can lead to ‘over diagnosis’,” he explains. “This means that some slow growing cancers, that may have gone undetected without causing harm to the patient, are now detected with routine screening in a patient without symptoms. Once diagnosed, the cancer is then treated – and the outcome is not always beneficial to the patient.”

According to Dr Eedes, a high percentage of prostate cancers are indolent or extremely slow growing.

“The problem is, once a cancer is detected, there is the imperative to do something. This can lead to many men receiving unnecessary treatment. Of great concern is that this treatment may negatively affect the quality of these men’s lives. Most patients treated for prostate cancer will have various side effects, which may include incontinence, impotence, anxiety, etc. All anti-cancer treatments have risks and side effects and this is accepted if treatment benefits the patient. However, if treatment does not lead to benefits such as increasing the length and quality of their lives then this harm is done for no good and it is difficult to justify this.”

For this reason, says Dr Eedes, it’s essential that patient and doctor debate the use of routine testing upfront. “The term ‘shared decision-making’ is now used,” he says. This prevents a scenario where patients are not fully informed of the consequences of their treatment choice and then have to deal with the fall-out afterwards.

“It is difficult to defend the current trend of just doing the PSA (prostate-specific antigen) blood test on a man without all the issues being discussed first,” says Dr Eedes. He likens it to the issue of counselling and getting consent from patients upfront before HIV testing.

This must be seen in the context of rapidly rising costs of cancer treatment globally and locally. The Independent Clinical Oncology Network (ICON) – a network of over 100 independent clinicians working in oncology in South Africa – is working towards encouraging the adoption of more cost-effective, evidence-based cancer treatment protocols and pathways.

“The ICON Clinical Treatment Protocols are unique in that they differentiate treatments by intent, i.e. what the aim of the treatment is – to cure or to palliate,” Dr Eedes explains. “We would like the biggest spend to be where the most impact is made: ‘bang for buck’. The Protocols take cost, affordability and local conditions into account.”

ICON uses clinical and cost data gathered from the insured patient population via its online treatment authorisation system (eAuthTM) to examine trends, measure compliance to protocols and measure behaviour of the clinician network. This ultimately enables it to determine more accurately how diseases are being treated in the real world.

“This data allows us to plan ahead and detect trends, both positive and negative. There is nothing else like it in the country,” says Dr Eedes.

One of the trends that we hope to be able to detect from the data is the approach of ‘Active Surveillance’. This is a treatment pathway where patients with low risk, non-aggressive cancers are closely monitored and active treatment with surgery or radiation is delayed until it is needed. This has been found to be both safe and preferable to immediately resorting to invasive treatments with all the negative side effects that go with that. Many patients may never need their cancer treated for the duration of their lives. This is an internationally recognised approach to managing prostate cancer and ICON is promoting its proper place in the treatment of this disease.

Unfortunately, says Dr Eedes, doctors “are not incentivised to follow this path”. To do this treatment properly requires resources and time and this is not always recognised by medical aids. “Despite the fact that it allows for a much more rational use of limited resources and has excellent outcomes for the correct patient, if doctors are not well reimbursed for their time and expertise, it will not fly.”

He stresses that the approach is not about cost cutting or undertreating (under-servicing) patients to save money. “The term ‘cost-effective’ takes both the cost and the beneficial effect to the patient into account,” he says. “To have a cheap but ineffective treatment is not cost-effective.”

In theory, says Dr Eedes, this approach will free up resources to enable more treatment for those who really need it.

Dr Eedes says that more work needs to be done to find better ways of being able to stratify patients into those that have a prostate cancer that will remain dormant and can be watched (Active Surveillance) and those that will benefit from early treatment. Fortunately, new developments in prostate cancer research could narrow down both screening and treatment to those who really need it.

“Currently we use broad tools to prognosticate and guide patients.  Sophisticated prognostic testing, using gene microarray assays, – still experimental and extremely expensive, may be able to provide better guidance in the future,” he says.

“The ultimate goal is to be able to determine the appropriate treatment for the appropriate patient by the appropriate specialist, with the aim of achieving the most beneficial outcome.” he concludes.

November is ‘Movember’ – Prostate cancer awareness month. For more information on the Independent Clinical Oncology Network, please visit www.iconsa.co.za

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