CureTalk Interviews E. Michael D. (Mike) Scott Part 2: PSA Test, Research, and IMF
Me: Can changes in lifestyle bring about a change in risk of getting prostate cancer? Do we have any data talking about the relation between lifestyle and prostate cancer?
Mike: I know of no really compelling data, available today, that show any definitive linkages between lifestyle and risk for a diagnosis of prostate cancer. We still have no idea why most men get this disease. We do of course know that things like working in cadmium mining and refining come with a significant increase in risk for prostate cancer, but that accounts for very few of the vast number of prostate cancers that occur around the world. We also know that smoking causes many cancers, so smoking is a lousy idea. However, I don’t think we are anywhere near being able to say that a healthy lifestyle of any specific type will lower risk for a diagnosis of prostate cancer. There are lots of data – but often they are contradictory. Having said that, there does seem to be sufficient data to argue with a reasonable degree of belief that eating large amounts of red meat is probably not the greatest idea if avoiding prostate cancer is among one’s priorities.
By contrast, after a man has been diagnosed with prostate cancer, we know that lifestyle can be very important to the speed at which the disease progresses. Indeed lifestyle changes alone can be sufficient, in many men, to significantly alter risk for any progression of their disease (even if they are just on active surveillance or watchful waiting protocols). My usual suggestion to most men who get diagnosed with prostate cancer is straightforward: lose any excess weight that you can; start to exercise regularly; make adjustments to your diet so that it is much more like a Mediterranean “heart healthy” diet, with more fruits and vegetables and less red meat and carbohydrates. I am conscious that moving to Vegan-like diets can be beneficial, but for most Westerners this is really hard. I am also conscious that many patients swear by a multitude of different supplements and other “alternative” agents. My view is that if these have no significant known side effects and they make the patient feel good, then fine, but the data are commonly less than compelling. Lifestyle changes can be particularly important for men with progressive forms of prostate cancer because they may help the patient to deal with the side effects of some types of drug therapy.
Me: Of course, no prostate cancer discussion is complete without the mention of the PSA test controversy. What is your take on this?
Mike: Ah yes. The perennial controversy. So let’s get one thing out of the way first. The PSA test is excellent (for the majority of men) in being able to assess risk of biochemical recurrence after treatment and the aggressiveness of that recurrence (through the use of the PSA doubling time). However, even in those settings, there is a small subset of “low producers” of PSA for whom the interpretation of PSA data can be very challenging because their levels are always relatively low and changes appear to be small.
As a diagnostic/prognostic test, in contrast, the PSA test (in my view) is “only” the best we have to indicate a base level of risk for prostate cancer. However, we use it badly. We misunderstand what any one test level can tell us. And we have elevated its importance to a completely unreasonable level.
It would be impossible in an interview like this to give a detailed set of comments on how I think about the application of the PSA test but there is a small set of pieces of advice that I would offer.
(1) Get a PSA baseline done in your 40s (or perhaps your late 30s if you fall into a high risk group – as do most African American and Afro-Caribbean men). Ideally, this ought to be down at < 0.7 ng/ml.
(2) If any specific PSA result seems unusual compared to your prior result, don’t just rush off and get a biopsy! First, just get a repeat PSA test done, maybe a month later, by the same laboratory (so that you can compare apples to apples). PSA levels go up and down depending on things as simple as the time of day you have the test done. My own PSA level at age 65 is “normally” about 1.5 ng/ml. On three occasions now it has gone up to as high as 4.5 ng/ml but has gone back down again within a couple of months to its normal level.
(3) Patients need to get a very clear message from their doctors that a PSA test actually tests you for possible risk of prostatic disorders of many types. It is not, in any way, a test that is specific for prostate cancer in an otherwise healthy male.
(4) Annual, mass, population-based screening with the PSA test finds a lot of what we call prostate cancer today, but at least half and perhaps a lot more of the prostate cancers found as a consequence of such screening tests are clinically insignificant, placing the patient at high risk for over-treatment.
Bluntly, we need much, much better tests than the PSA test if we are ever going to be able to screen men effectively for real risk of clinically significant prostate cancer. Until we have such tests, and they have been properly validated, we are stuck with the PSA test, “warts and all.”
Me: New tests for prostate cancer were described in an article in The New York Times just the other day. It seems like the test developers are having a competition. Do you think these tests can help the men who really need them?
Mike: Some of the most important information that was provided in that article in The New York Times actually appeared not in the article at all but in the accompanying video interview with Peter Scardino of the Memorial Sloan-Kettering Cancer Center. It has been my good fortune to have known Dr. Scardino for more than 20 years. The critical point that Dr. Scardino makes is that we need to be doing a much better job of diagnosing and treating clinically significant prostate cancers and avoiding the treatment of clinically insignificant prostate cancers. As I mentioned in my answer to your prior question, Dr. Scardino also believes that at least 50% of the prostate cancers getting diagnosed in America today are clinically insignificant, and far too many men are getting biopsies that they really don’t need. Some of the new tests that are coming available may well help us to avoid biopsies in men who historically we have biopsied obsessively. But the real issue here is behavioral. Are our physicians really ready to start being much clearer with their patients about all the risks associated with over-treatment and the very evident data showing that many men are actually being diagnosed with “disease” that will never have any clinical impact during their otherwise rather healthy lives?
Me: What, according to you, have been two of the most important/seminal prostate cancer research that have/could turn the tide in the management of prostate cancer?
Mike: First and most importantly is the growing understanding that is true for many types of cancer: prostate cancer is not one disorder. The Prostate Cancer Foundation here in the USA now believes that – based on work done at the University of Michigan and other institutions around the world –there may be as many as 25 different subtypes of prostate cancer. This knowledge is only beginning to help us to think in much better ways about the forms of treatment that may be appropriate for specific individuals with specific subtypes of prostate cancer. So far, with respect to the actual clinical management of the disease, we have only just opened this envelope and started to peek inside. Second, we are seeing a potential future revolution in the use of minimally invasive and focal therapies for the treatment of localized forms of prostate cancer. This revolution is also at very early stages; some of the clinical research needed to support the real efficacy and safety of various types of minimally invasive and focal therapy still needs to be done. Exactly how opportunities in this field many play out over the next 20 years are hard to predict, but just as we look at bilateral orchiectomy today as being an effective but somewhat primitive means for treating metastatic prostate cancer, my suspicion (and hope) is that 20 years from now we will look at traditional, nerve-sparing radical prostatectomies (whether done as open surgeries or using a da Vinci robot) as having been an effective but rather primitive means of managing localized prostate cancer.
Me: You are also on the board of directors of the International Myeloma Foundation (IMF). And the last year has been really good in terms of myeloma research with two new drugs begin approved by the FDA and myeloma expert dropping the “cure” word very often in various webinars and teleconferences. Please comment on your IMF experience.
Mike: As with prostate cancer, I “fell into” a relationship with the IMF because of my professional career in health care communications. The company I was running was asked to work with the IMF to develop and manage the very first live educational program that the IMF ever put on (back in 1992). When I was invited to join the Board of the IMF in 1994 the median life expectancy after a diagnosis of myeloma was about 3 years. Now it is very nearly 5 years, but much more importantly there are patients who are living 10, 15, and 20 years after a diagnosis of myeloma.In late 1995, Michael Katz and I were able to persuade Suzie Novis that the IMF needed a web site … which revolutionized the relationship between newly diagnosed patients and the IMF. Do I think we are near to the point where we can look at some patients and tell them there is a high probability that they can be cured? Yes, I do. And the IMFs new “Black Swan Research Initiative” is highly focused on exactly this. But, as with prostate cancer, myeloma is a spectrum of diseases, not just one. All the new drugs approved since the early evidence of the activity of thalidomide in the late 1990s have helped to change the way we think about myeloma management … and the number of new drugs in the development pipeline is unimaginable by comparison with even 15 years ago. The challenge we face today is ensuring that patients who really need some or all these new agents can really have access to them. For some patients, the costs of the new agents are simply prohibitive.
Thank you, Mike. It was great connecting with you.