Issue 6 / May  2016  

The following articles are focused on prostate cancer screening for men and active surveillance for those recently diagnosed with prostate cancer.  Since many of you reading this newsletter have already undergone treatment for prostate cancer, you may ask yourself "so what"?  The answer is that you can serve an important role as advisor to relatives, friends and coworkers (at least the ones you like ;D) who may be undecided as to whether or not to get screened or what to do if recently diagnosed.  At the very least, you could pass on the below articles.  Thanks for reading and paying it forward.... 
Best Regards,
R. Alex Hsi, MD
PPI Sponsored Golf Tourney, August 6th . To register, go to  Kitsap Cancer Services  for more information.
PSA Screening for Prostate Cancer - The Debate Rages On
In March 2016, the Centers for Medicare and Medicaid Services (Medicare) temporarily suspended the development of a measure to discourage PSA screening for prostate cancer in all men.  The United States Preventative Services Task Force (USPSTF) currently is updating its 2012 recommendation against PSA based prostate cancer screening.  To date, Medicare has paid for PSA testing, but there are clearly forces in government that may change that policy.
The recommendation against PSA screening by the USPSTF was based largely on the PLCO trial, a large study published in 2009 that showed no difference in deaths from prostate cancer in a screened (intervention group) and non-screened (control group) population of men.  A major criticism of that study was that nearly 50% of the control group actually did have a PSA test during the time they were enrolled in the study.  A recent letter published in the New England Journal of Medicine (Shoag et al, NEJM 374:18, 1795-6, May 5, 2016) points out that the number of men in the supposed non-screened control group who actually received PSA testing was much higher than 50%.  The authors show that nearly 90% of men in the control group had undergone at least 1 PSA test either before or during their enrollment in the study.  In fact, based on a follow up survey of both groups, the control group actually had more cumulative PSA testing than the intervention group!  This finding seriously calls into question the validity of the data the USPSTF used to make its recommendation.  The fact that this letter was published in the New England Journal of Medicine will likely create further discussion and it will be interesting to see how Medicare and the US government respond.  Stay tuned!!
To read the published letter, click here:  Reevaluating PSA Testing Rates NEJM
Active Surveillance for Prostate Cancer - Not for Everyone

A recent report from Sunnybrook Health Sciences Centre at the University of Toronto (Yamamoto et al., Journal of Urology 195:1409-1414, May 2016) analyzed a group of 980 men who underwent active surveillance after being diagnosed with prostate cancer.  Clinical and pathological features were studied to see which features were associated with the development of metastatic (spread of tumor to the lymph nodes or bones) prostate cancer.  The study found that 30 patients (3.1%) developed metastases in a median of 6.3 years after diagnosis.  The risk factors for developing metastases were a PSA doubling time of less than 3 years, having Gleason score 7 cancer on biopsy, or having 3 or more positive biopsies at the time of diagnosis.
The conclusion of this study was that prostate cancer patients with any of the above risk factors at the time of diagnosis should be offered active surveillance with caution.  If one does choose active surveillance in this situation, further testing with MRI/newer genetic marker tests should be considered to help insure that the patient does not harbor more aggressive disease.

More Evidence for a Link Between Breast Cancer and Prostate Cancer
Three studies suggesting a link between the genetic mutations for breast cancer (BRCA1 and BRCA2) and prostate cancer were presented at the annual meeting of the American Urological Association in San Diego, CA in early May, 2016. 
The first study from SUNY Upstate Medical University in Syracuse, NY was a combined review of 12 previous studies including 261 men with prostate cancer who tested positive for the BRCA2 mutation.  Researchers found that 17.4% of the men with the BRCA2 mutation presented with metastatic prostate cancer versus only 4.4% across the general population.  In addition, men with the BRCA2 mutation were much more likely to be diagnosed with late or advanced stage prostate cancer - 40.3% compared with 10.8% of the general population.
The second study reviewed blood DNA samples from 857 prostate cancer patients treated at the Walter Reed Military Medical Center in Bethesda, MD.  Researchers found that African American prostate cancer patients were three times more likely to have the BRCA1 or BRCA2 mutation than Caucasian patients (7.3% vs. 2.2%).  In addition, African American patients were more likely to develop metastatic prostate cancer (9.4% vs. 2.4%).
The final study focused on men who had been previously treated for breast cancer.  Researchers from Illinois reviewed over 5700 cases of male breast cancer and found that there was an increased risk in those men of developing prostate cancer.  Depending on the age at diagnosis of breast cancer, stage and hormone receptor status, the risk of developing prostate cancer in men with a prior breast cancer ranged from 23%-36% higher than the general population.  These data suggest that prostate cancer screening should be strongly recommended in men with a personal history or even family history of breast cancer.
Taken together, these studies identify a subset of men who are at elevated risk for prostate cancer and, in particular, aggressive prostate cancer.  This group may benefit from more intensive monitoring and early treatment.
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