Ladies first: prostate and breast cancer are related—they are both triggered by poor detoxification of 800+ chemicals in the environment dubbed xenoestrogens by microbiome and liver. The worst are pesticides, heavy metals and plastics. BTW, quit drinking out of plastic bottles, and do not fear phytoestrogens like soy—it helps lower the risk, and even treat cancer! It is best to eat it organic and fermented, like tofu.
I am one of the doctors who have put the gloved finger away. No more rectal exams, so, it is safe to go come back to see me, guys. BUT (pun intended,) I do recommend the blood PSA test. Below, you will see that it too has been under fire. I agree with the articles quoted, and for the reasons stated—most men with prostate cancer die of something else. Besides, the outcome does not vary much, regardless of treatment (or not treatment) in most cases.
The reason I still recommend the PSA is because an elevated value can serve as motivation to eat your veggies and improve intestinal and liver function. Adding certain supplements, the PSA does drop significantly, reducing the risk of cancer advancing, and improving overall health. You would also lower the risk of chronic disease, and even reduce the risk of cancer in other organs. I also recommend a prostate biopsy from a urologist for patients who want to be sure they are not missing out on any potential treatment.
I highly recommend that you take the time to study the references.
References
94% of plastic water bottles have plastic fibers in water, USA Today March 15 2018
Treatment with Phytoestrogens Reversed Triclosan and Bisphenol A-Induced Anti-Apoptosis in Breast Cancer Cells.
J. Europe PMC 2018 DOI: 10.4062/biomolther.2017.160 (PMID:29310425)
Triclosan (TCS) and bisphenol A (BPA) are endocrine-disrupting chemicals that interfere with the hormone or endocrine system and may cause cancer. Kaempferol (Kaem) and 3,3′-diindolylmethane (DIM) are phytoestrogens that play chemopreventive roles in the inhibition of carcinogenesis and cancer progression. In this study, the influence of TCS, BPA, Kaem, and DIM on proliferation and apoptotic abilities of VM7Luc4E2 breast cancer cells were examined. MTT assay revealed that TCS (0.1-10 μM), BPA (0.1-10 μM) and E2 (0.01-0.0001 μM) induced significant cell proliferation of VM7Luc4E2 cells, which was restored to the control (0.1% DMSO) by co-treatment with Kaem (30 μM) or DIM (15 μM). Reactive oxygen species (ROS) production assays showed that TCS and BPA inhibited ROS production of VM7Luc4E2 cells similar to E2, but that co-treatment with Kaem or DIM on VM-7Luc4E2 cells induced increased ROS production. Based on these results, the effects of TCS, BPA, Kaem, and DIM on protein expression of apoptosis and ROS production-related markers such as Bax and Bcl-xl, as well as endoplasmic reticulum (ER) stress-related markers such as eIF2α and CHOP were investigated by Western blot assay. The results revealed that TCS, and BPA induced anti-apoptosis by reducing ROS production and ER stress. However, Kaem and DIM effectively inhibited TCS and BPA-induced anti-apoptotic processes in VM7Luc4E2 cells. Overall, TCS and BPA were revealed to be distinct xenoestrogens that enhanced proliferation and anti-apoptosis, while Kaem and DIM were identified as natural chemopreventive compounds that effectively inhibited breast cancer cell proliferation and increased anti-apoptosis induced by TCS and BPA.
Little Evidence Supports Use of Digital Rectal Exam, Medscape – Mar 13, 2018, J. Ann Fam Med. 2018;16:149-154″In this Gleason 8+ group, we saw a 24% increase in absolute numbers [of prostate cancer diagnoses]. One-year biochemical recurrence (BCR) rose from 6.2% to 17.5% (P < .0001),” they report.
Ahlering and colleagues also performed a propensity score–matched analysis to rule out the possibility that the increase in high-risk disease was not due to referral patterns.
“For any given age and PSA, propensity matching demonstrates that there is now more aggressive disease in the post-recommendation era,” the researchers report.
“So these centers dispersed throughout the US have witnessed a tripling of BCR and a quadrupling of nodal metastasis,” the team concludes.
“The potential of an epidemiological shift towards high-risk disease raises concern for increased PCSM [prostate cancer–specific mortality], secondary interventions, and associated side effects,” they warn.
Population-Based Cohort
In a separate but related study, Linda Huynh, BS, clinical research assistant, University of California, Irvine, assessed the effect of the 2012 USPSTF recommendation in a population-based cohort.
Huynh also assessed national diagnostic patterns during three eras: 2004 to 2007 (era 1), 2008 to 2011 (era 2), and 2012 to 2015 (era 3).
In total, the researchers analyzed data from 1,380,219 men who had undergone radical prostatectomy in one of the three eras assessed.
“Pathological endpoints of p-stage, lymph node metastasis, and surgical margins were compared between screening eras,” the researchers note.
The investigators observed a 15.8% drop in surgical volume from both era one and era 2.
Importantly, the age at which men had undergone a radical prostatectomy dropped in the period 2008 to 2012 after an earlier USPSTF recommendation not to screen men aged 75 years and older (P > .001).
“In contrast, preoperative PSA experienced an upward trend from 69 to 67 and 73 ng/mL (P < .001),” the researchers observe.
The risk in absolute numbers of high-risk prostate tumors of Gleason score 8 to 10 also increased in a stepwise fashion — “meaning that as we get further and further away from the 2012 recommendations, each year we are seeing more high-grade disease, so it does not look as if we are plateauing,” Huynh explained to Medscape Medical News.
The investigators also reported a steady increase in diagnoses of prostate cancer with lymph node involvement across the three eras, from 1% in era one, to 2% in era 2, to 3% in era 3 (P < .001).
Similarly, the incidence of high-stage disease (pT3/T4) increased from 6% in era one, to 10% in era 2, to 19% in era 3 (P < .001).
After adjusting for age and PSA levels in a propensity score–matched analysis, the researchers also observed significant increases in positive surgical margin rates, tumor volume, and lymph node involvement.
Since era one, the USPSTF has made two recommendations against the use of PSA screening, first with respect to men aged 75 years and older, and in 2012, against PSA screening in men of all ages.
The USPSTF recently changed its recommendation on PSA screening. In 2017, an updated recommendation emphasized that the decision to undergo PSA screening must be individualized for men aged 55 to 69 years. For men aged 70 years and older, the USPSTF still does not recommend PSA-based screening.
Despite this backtracking, it appears the fallout from the 2012 null recommendation remains unchecked.
High-grade Shift
Asked by Medscape Medical News to comment on the high-grade shift in prostate cancer now being seen in the United States, Hein van Poppel, MD, PhD, professor of urology, University of Leuven, Belgium, pointed to data from the Scandinavian countries, where more intense PSA screening is performed.
“They have the best data, and they have the best outcomes showing that if you are screened for prostate cancer, the likelihood you will die from it is dramatically reduced,” van Poppel said.
“Everybody knows that screening decreases prostate cancer mortality,” van Poppel reaffirmed. “There is no way around it.”
He commented that the original finding that PSA screening does not reduce mortality, from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) study that was carried out in the United States, has now been overturned; when confounding factors are taken into account, the study does show an effect.
“The big problem with the PLCO study, and a major criticism of it, was that there was, in fact, widespread screening in substantial numbers of patients in the arm randomized to no screening,” van Poppel explained.
“So while this arm was not formally screened for PSA, men went to their doctor and had their PSA determined, so they were widely screened for PSA, and this meant that there was no difference in cancer mortality outcomes between the two arms, because of contamination,” he added.
As previously reported, a new analysis of data from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the PLCO trial now indicates that both studies support a prostate-cancer mortality benefit with PSA screening.
The new analysis showed a 25% to 31% lower risk for prostate cancer mortality in the ERSPC and a 27% to 32% lower risk in the PLCO among men who were screened compared to men who were not screened.
Dr Ahlering and Dr Huynh have disclosed no relevant financial relationships.
European Association of Urology (EAU) 2018 Congress. Abstracts 268 and 269, presented March 17, 2018.
Digital rectal examination (DRE) inadequately identifies risk for prostate cancer on a population level, according to a meta-analysis that compared DRE indications of elevated risk with biopsy outcomes. DRE and prostate-specific antigen measurement form the basis of population screening for elevated risk for prostate cancer. Both procedures may be part of a well-care visit to a primary care provider.
Studies have suggested DREs are associated with a high rate of false-positives and no reduction in prostate cancer mortality, while subjecting patients to unnecessary and invasive follow-up procedures and perhaps overdiagnosis and overtreatment of prostate cancer. Despite questions about DRE benefits, a recent survey found that 81.0% of primary care physicians in Canada report using it in their clinics.
Therefore, to better understand the effect of DRE, Leen Naji, MD, from the Department of Family Medicine at McMaster University in Hamilton, Ontario, and colleagues conducted a systematic review and meta-analysis of the diagnostic accuracy of DRE administered in the primary care setting as a screen for prostate cancer.
Naji and colleagues searched several databases for the terms “prostate cancer,” “digital rectal examination,” and “biopsy” in studies and systematic reviews that evaluated the effectiveness of DRE in screening for prostate cancer by primary care clinicians.
Their meta-analysis, published in the March/April issue of the Annals of Family Medicine, included 7 studies that enrolled a total of 9241 patients who underwent DRE. Diagnosis of prostate cancer was based on prostate biopsy.
The sensitivity of the pooled studies for DRE was 0.51 (95% confidence interval [CI], 0.36-0.67), and specificity was 0.59 (95% CI, 0.41-0.76). The pooled positive predictive value was 0.41 (95% CI, 0.31-0.52), and the pooled negative predictive value was 0.64 (95% CI, 0.58-0.70). The investigators conclude that DRE as performed by primary care providers does not meet the World Health Organization criterion of benefits of a screening test outweighing harms.
“On the basis of the lack of evidence supporting its use, we do not recommend routinely using DRE as a screening tool for prostate cancer in primary care, unless it is proven effective in future studies. Additionally, although we did not study possible harms of DRE, its invasiveness and potential to lead to unnecessary biopsy, overdiagnosis, and overtreatment argue against its routine use,” the researchers conclude.
Limitations of the meta-analysis include the variability of the studies, in terms of who actually performed the DREs; absence of an accepted universal definition of abnormal DRE; and the lack of controls. In addition, the false-negative rate could not be ascertained because men with negative results didn’t progress to biopsy.
No Mortality Benefit With ‘One-Off’ PSA Test, Medscape – Mar 06, 2018
The recent publication of the third major randomized trial of prostate-specific antigen (PSA)-based screening for prostate cancer reported no difference in prostate cancer mortality after a median follow-up of 10 years in more than 400,000 men in primary care practices across the United Kingdom. Unlike the US Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial, which also found no benefit, the UK trial evaluated a single invitation to PSA testing, rather than annual screening, and minimal testing occurred in the control group.
My primary care colleagues and I are still waiting for the US Preventive Services Task Force (USPSTF) to finalize its nearly year-old draft recommendation statement on prostate cancer screening, which I characterized in a Medscape commentary as a “surprising reversal.” Rather than discouraging PSA screening for men of any age, the USPSTF instead advised that we routinely discuss the potential benefits and harms of screening in men aged 55-69 years and screen men who desire the test. I disagreed with this stance, which I think is analogous to advising clinicians to routinely discuss the potential benefits and harms of antibiotics for viral infections, or the potential benefits and harms of MRI in patients with uncomplicated acute low back pain.
Others are contributing to the PSA debate in the pages of cancer journals, as a recent Medscape article reported. In a position statement published in the Journal of Clinical Oncology, a group of prominent urologists discussed the drop in PSA testing and prostate biopsy rates since 2012 and the rise in the percentage of men diagnosed with prostate cancer presenting with metastatic disease, which began around 2007 but now seems to be rising more sharply. They argued that in contrast to past years, when we were doing too much screening, too little screening is now being done, and they worry that a rise in morbidity and mortality from prostate cancer will follow. In order to get screening “just right,” they propose two solutions:
- For urologists, identifying and validating biomarkers to determine which patients with high PSA levels need prostate biopsy
- For primary care physicians, “to engage in [more] conversations regarding screening that are individualized and centered on shared decision-making”
I agree that the data show that primary care physicians are doing less PSA testing, but the metastatic prostate cancer statistic, derived from a study of the National Cancer Institute’s SEER database, is misleading at best. We know that a substantial proportion of prostate cancers detected by PSA screening are overdiagnosed and would never become metastatic. Less PSA testing means that we are finding fewer of these cancers-in-name-only, so the proportion of all prostate cancers that are metastatic at diagnosis rises as a result. This is likely to be a statistical quirk rather than an early indication that less PSA testing will lead to more deaths.
As for having family physicians do more shared decision-making with men about PSA testing, a commentary in JAMA Oncology by an internist and two oncologists argued that such discussions are a “mirage” in the real world of primary care. The authors asserted that in contrast to guideline recommendations, “the majority of decisions about PSA testing are not shared but made unilaterally by primary care physicians” due to multiple barriers, including time, competing demands, and a dearth of data on how race and family history affect one’s risk for clinically important prostate cancer and the benefits and harms of screening. Further, they compared an elevated PSA level to “quicksand,” where a cascade of invasive diagnostic interventions with scant supporting evidence can follow in rapid succession and create an unstoppable momentum of their own.
Welcome to my world! Even though few family physicians are as familiar as I with the data and available resources for shared decision-making, most of my patients end up being totally perplexed and either defer the PSA screening decision to a spouse or significant other (who, naturally, wants them to be tested) or say, “Whatever you want to do is fine by me, doc.” And in the precious time it takes for us to recognize this shared decision-making mirage, I may miss an opportunity to offer something else that clearly benefits my patient, such as colorectal cancer screening or tobacco-cessation counseling. This tradeoff is a potential harm of shared decision-making that neither the current USPSTF nor academic urologists fully recognize. It is the reason that I persist in telling colleagues and students that the amount of PSA screening that’s “just right” should be a lot closer to none at all.
More High-Risk Prostate Cancer Now in the US Than Before, Medscape – Mar 27, 2018.
COPENHAGEN, Denmark — More men are now presenting with higher-grade, more invasive prostate cancer in the wake of 2012 recommendations from the US Preventive Services Task Force (USPSTF) not to routinely screen asymptomatic patients to detect early disease, more epidemiologic evidence indicates.
As predicted by urologists in 2012 after the recommendations were released, there has been a consistent, stepwise increase in cancers of higher Gleason score, as well as a stepwise increase in the median level of prostatic-specific antigen (PSA), in the 4 years after the USPSTF recommendations were released compared to the 4 years before the recommendations were issued.
At the same time, both surgical volume and the proportion of low-grade cancers have been dropping, as reported by Thomas Ahlering, MD, University of California, Irvine, and colleagues during a poster session of the European Association of Urology (EAU) 2018 Congress.
“Treating high-risk disease has its limitations, because you are not going to cure the majority of patients no matter what you do, so the better answer is to diagnose prostate cancer earlier,” Ahlering told Medscape Medical News. “If our data are correct, the most important thing to do is to start screening more intensely again,” he reaffirmed.
In one of two related studies, Ahlering and colleagues carried out a retrospective analysis of nine high-volume referral centers throughout the United States to compare patients who presented with prostate cancer of Gleason grade 8 or higher and who had seminal vesicle and lymph node involvement before the 2012 USPSTF recommendations were issued with such patients after the recommendations were issued.
A total of 19,602 men were analyzed; 4-year average diagnoses were compared between October 2008 and September 2012, and between October 2012 and September 2016, before and after the recommendations had been released.
The researchers observed a 22.6% reduction in surgical volume in the postrecommendation period compared to the prerecommendation period.
They also noted an increase in the median PSA level from 5.1 ng/mL prior to the recommendations to a median of 5.8 ng/mL after they had been released (P < .001).
The mean age at the time of diagnosis also increased, from 60.8 years before the recommendations to 62 years after the recommendations (P < .001). “Expectedly, the proportion of low-grade Gleason 3+3 cancers decreased from 30.2% to 17.1% (P < .001),” the investigators write. In contrast, the incidence of high-grade Gleason 8+ prostate cancers increased from 8.4% prior to the recommendations to 13.5% after the recommendations (P < .001).
