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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Cancer

May 24, 1999

News this month
Canadian researchers track first drop in prostate cancer deaths

There has been a significant decline in prostate cancer deaths since 1995 in Canada and Quebec, a group of well-known cancer researchers reported this spring. The drop — as great as 23 percent in Quebec in one particular year — is even larger than that seen in the U.S. since the early 1990s.

Encouraging news
The study, reported in the April issue of Journal of Urology, is encouraging news for both the public and physicians alike. Prostate cancer deaths rose throughout the 1980s, despite the introduction of new screening techniques and treatment methods. In 1990, deaths from prostate cancer in the U.S. reached their peak, then declined 6 percent between 1990 and 1995. The cause for the decline in the U.S. has not been clearly established.

One thing was clear: the decline in deaths was not due to a reduction in the numbers of prostate cancer cases. On the contrary, the number of prostate cancer cases rose as a consequence of screening with the PSA (prostate specific antigen) blood test.

Deaths fall as cases increase
The current research, led by François Meyer and Lynne Moore at the Laval University Cancer Research Center in Quebec, investigated the rate of mortality due to prostate cancer in Canada in the early 1990s. They also wanted to identify the causes of the decline.

One thing was clear: the decline in deaths was not due to a reduction in the numbers of prostate cancer cases. On the contrary, the number of prostate cancer cases rose as a consequence of screening with the PSA (prostate specific antigen) blood test.

Too soon to see benefits from PSA screening
Researchers believe that increased PSA screening to find prostate cancers in the earliest stages was not the primary reason for the decline. The time lag between the start of widespread PSA screening and the onset of the disease was too short. Researchers do not anticipate a reduction in deaths until 10 to 15 years after PSA screening began, if at all.

What the researchers found
The researchers obtained data on all deaths from prostate cancer between 1976 and 1997 in Quebec, and 1976 and 1996 in Canada. They found prostate cancer death rates increased regularly until 1991 in Quebec and Canada. After 1991, the rates decreased moderately until 1995 and then more markedly in 1996. There was a further decline in 1997 in Quebec.

Overall, deaths from prostate cancer dropped by an incredible 23 percent in Quebec from 1991 to 1997, and by 9.6 percent in Canada between 1991 and 1996. Deaths in men of all ages declined, but were even greater in men younger than 75 years.

Role of hormone therapy
If increased PSA testing was not lengthening the lives of men with prostate cancer, what was? The researchers suggested hormone therapy — reducing the amount of the male hormone testosterone, either through medication or surgically — played a significant role in extending lives. Past trials have shown survival improved when hormonal treatment began at diagnosis of advanced prostate cancer, rather than waiting to start it later.

Future studies
The researchers are currently investigating whether the timing of the introduction of hormone therapy plays a role in the survival of more than 8,000 men with prostate cancer. They also noted the more studies, the better the chances of understanding the complexities in diagnosing and treating this widespread disease.


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John W. Colberg, MD

The dilemma of prostate cancer

What's interesting about this article coming out of Canada is that they reported a significant decrease in mortality from prostate cancer, which has never really been shown before. Is this decline due to widespread PSA testing? No. These physicians are probably detecting more advanced cancers using PSA screening, which are then being treated with hormonal therapy and therefore stretching out the lifespan of the patients studied. This group of physicians has long favored using hormone therapy early when treating advanced prostate cancer.

Prostate cancer is the second leading cause of cancer deaths in American men after lung cancer. For the past few years, PSA testing may have been understood by the public as something it is not — the one and only answer in detecting prostate cancer. Indeed, the PSA test is not perfect. Other diseases of the prostate, such as infection and benign prostate enlargement, can result in elevations of the PSA level. With increased PSA testing, the number of prostate cancers diagnosed in recent years has skyrocketed. This year, 180,000 cases are expected to be diagnosed.

“If we concentrate on screening people selectively, we will still identify the men who will benefit from treatment, while avoiding putting other men through needless procedures and suffering as a result. ”

True, PSA testing is picking up cancers at earlier stages than ever before, but it also picks up cancers that may never become life-threatening in certain patients. If we concentrate on screening people selectively, we will still identify the men who will benefit from treatment, while avoiding putting other men through needless procedures and suffering as a result.

Who should get a PSA test
If you are 80 years old, there's no reason to get a PSA level because chances are you would die of something else before prostate cancer. But I believe those men aged 50 and older with at least a 10-year life expectancy, or younger men (in their 40s) at higher risk for prostate cancer, should continue to be screened with a PSA and digital rectal exam annually. Men at high risk for prostate cancer include:

  • Those whose father, uncle or brother had prostate cancer
  • African-American men.

If you are concerned about prostate cancer, ask your physician:

  • if you have any risk factors that would put you at higher risk.
  • what are the benefits of treating an early cancer versus the risks of biopsy.
  • what are the treatments for prostate cancer, their success rates and any side effects.

Deciding on treatment
If there were only one treatment for prostate cancer with proven results, then all of this would be very simple. But there are many options for treating prostate cancer, including:

  • external beam radiation therapy
  • radioactive seeds implants (brachytherapy)
  • combination of radioactive seed implants and external beam radiation therapy
  • "watchful waiting"
  • treatment with medication (hormones)
  • surgical removal of the prostate (radical prostatectomy)

When a patient is presented with all these options, it can be difficult to decide what's the best treatment.

Important factors in choosing treatment:

  • Your age
  • Your medical condition
  • Stage of disease
  • Your own wishes

The role of age
The big debate these days is brachytherapy versus surgery. For older patients — those men near or older than 70 and who have other medical problems that could make surgery risks greater — brachytherapy (implantation of radioactive seeds into the prostate to destroy cancerous tissue) may be a better option. For a young healthy man, removal of the prostate may be the best treatment.

Do your homework
A lot of patients who come to me have already done their homework. It is important to try to give patients all of the information available so they can make a good decision. I also recommend patients:

  • seek a second opinion.
  • know the risks and advantages of each procedure.
  • talk to friends who have undergone these procedures.
  • consider quality of life issues in their decision.

Dr. Colberg is a urologist at Yale-New Haven Hospital and an assistant professor of surgery and director of uro-oncology at the Yale University School of Medicine.


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