March 2, 2016

Calgary’s Prostate Cancer Centre and the Southern Alberta Institute of Urology strongly reject the opinion of James Dickinson and his co-authors in the March 1st, 2016 CMJA OPEN. Entitled: “Trends in prostate cancer incidence and mortality in Canada during the era of prostate-specific antigen screening.” This group, whose membership includes no one dedicated to treating prostate cancer, has missed the mark in their recommendations against PSA screening. If followed, we would regress to a time when men are diagnosed with prostate cancer at later stages, and suffer higher morbidity and death rates. The cost to the healthcare system of treating advanced disease is significantly greater than treating early stage disease.

The PSA test remains our most important tool in diagnosing prostate cancer, and we support screening men who are properly informed. Through individualized and shared decision-making, we have lessened the chance of unnecessary treatment. We are proud to set the standard for supportive care before and after treatment, and we are also leveraging PSA screening to empower men to be more active in their health care.

While some prostate cancers grow rapidly and metastasize or spread, others grow very slowly and are unlikely to metastasize. This low risk prostate cancer may not need to be treated as soon as they are diagnosed. Slow growing prostate cancer may not have time to cause significant problems and the complications and side effects of treatment may outweigh the advantages. In Calgary’s Prostate Cancer Centre’s active surveillance clinic, men are carefully monitored. Treatment can be given if the cancer is progressing or if the patient decides on further treatment. Over treatment of men with low grade cancer is not an issue in Calgary.

We would welcome any members of the media or anyone from the public, to come to Calgary’s Prostate Cancer Centre and talk to any one of our Urologists, staff, or patients working in the field of prostate cancer to see the world-class clinical work that is being provided to our patients and their families.

Sincerely,

Kevin V Carlson MD FRCSC DABU
Clinical Associate Professor and Section Head of Urology
Department of Surgery
Cumming School of Medicine
University of Calgary

Geoffrey Gotto, MD, MPH, FRCSC
Clinical Assistant Professor, Department of Surgery, The University of Calgary
Southern Alberta Institute of Urology

Eric Hyndman, MD, PhD
Urologist, Clinical Assistant Professor
University of Calgary, Southern Alberta Institute of Urology

Bryan Donnelly, MD, MSc, FRCSC
Urologist
Clinical Associate Professor, University of Calgary
Co-Founder & Chairman, Prostate Cancer Institute, Calgary

The term “research” and “researchers” are misleading as there is actually no original research being printed here. This is population-based data extrapolated from overlapping databases which are prone to coding error and misclassification.

The real research published on the subject includes data from randomized-controlled trials showing a reduction not only in mortality, but also in the development of metastatic disease which can cause debilitating pain and loss of independence as well as necessitate systemic treatment with hormonal therapy and chemotherapy.

It is very flattering to have the “researchers” speculate that the “evolution of treatment” is responsible for more of the observed mortality benefit. The fact is that surgery and radiation treatments have not changed dramatically over the past decades in their ability to cure disease. What has changed is that we are now able to identify significant cancers before they have become to advanced to be cured with either modality. The evolution of new systemic therapies for advanced prostate cancer has not cured patients but only delayed mortality and palliated symptoms.

It is true that most men with prostate cancer die of other causes. This is largely because of early diagnosis and timely intervention. The reality is that prostate cancer is still the 2nd most common cause of cancer-related death in men in our country and that advanced disease often results in significant morbidity for our patients.

Dr. Dickinson seems to argue that ignorance is bliss and that men harbouring low-risk prostate cancer should not be burdened with this information as they are unable to grasp its significance. Frankly, this is insulting. A decent clinician should have no problem explaining the difference between a low and high-risk prostate cancer and the rationale for active surveillance in men felt to be at low-risk for disease progression over time. In reality, active surveillance is now used in close to 50% of men diagnosed with prostate cancer.

These researchers claim that “surgery, chemotherapy, and radiation cause harm because of the physical and mental toll on the body.” That’s hard to argue with. Nobody is saying that cancer treatment is something to look forward to. Rather than abandoning screening altogether and simply palliating patients at the end of life perhaps it would make more sense to focus our efforts on reducing the morbidity of these treatments. This is something we have been working on for years at the Prostate Cancer Centre and, frankly, Dr. Dickinson’s comments are unfounded.

The focus should be on identifying “cancers that would invade and kill” as the “researchers” put it and that is exactly why we are currently doing a large provincial biomarker study to identify new markers or panels of markers to be used in conjunction with PSA to direct treatment appropriately through the Alberta Prostate Cancer Research Initiative (APCaRI).

It is nice to see the “researchers” point out that mortality from prostate cancer is declining steadily at a rate of 3.25% per year. It is true that this is greater than one would expect and that refinements in surgical and radiation therapies are likely at least partly responsible but most actual research on the subject suggests that around 50% of this benefit is attributable to screening.

Dr. Dickinson also points out a few of the many flaws in his publication including the “changes in how deaths were reported” over time which is one of the fundamental flaws with the type of analysis he presents in his paper. Do not be fooled by this publication. This is not research. This is a retrospective analysis of suspect data evaluated with incredible bias against PSA screening. I would encourage anyone who is interested to look at the most recent publications from the ERSPC study which show mortality curves which continue to diverge at 14 years of follow-up suggesting that the benefits of PSA screening are more pronounced the longer you live, with a >40% reduction in death from prostate cancer with appropriate screening. Prostate cancer, like pancreatic cancer and many other far more lethal malignancy, is typically advanced and incurable by the time it becomes symptomatic and so his strategy misses the point.

As specialists we are actually NOT “telling a lot of patients that they have cancer and need to be treated.” As mentioned previously we are strongly in favour of active surveillance and expectant management in appropriately selected patients. It is true that we are “over-diagnosing” prostate cancer in that roughly 50% of patients meet this criteria. Over-diagnosing is certainly preferable to under-diagnosing when it comes to cancer. It is important to avoid over-treatment by selecting only those patients felt to be at high-risk of progression for treatment. Contrary to his statement that “many middle-aged men are undergoing invasive treatments at the first sign of potential for prostate cancer,” ….

“If we survive long enough to get prostate cancer things have gone pretty well.” Tell that to my patients in their 40s and 50s who present with metastatic disease and never had the benefit of screening because their family physician was swayed by meaningless propaganda by people like Dr. Dickinson. Dr. Dickinson feels that we do not need to concern ourselves with deaths related to prostate cancer in “old men, men over the age of 75.” I disagree. I plan to live a long life and have many patients who live well into their 90s who have been cured of prostate cancer and live meaningful lives well after 75. But maybe we should get let these “old men” die?

I agree with Dr. Dickinson’s comment that we “need to find a better way.” But abandoning established methods to diagnose prostate cancer at a curable stage is not the means to a better way. Perhaps he should focus his efforts on the development of new biomarkers or refining imaging for the diagnosis of high-risk prostate cancer with MRI and other modalities rather than fixating himself of doing away with PSA screening and waiting for men to develop symptomatic disease before referring them for treatments which are typically only palliative at that stage.

The only person “raising anxiety and making people worry about this” is Dr. Dickinson. His comments are inflammatory and insulting to the people who have dedicated their lives to treating prostate cancer and to the patients and family members of those who have been affected by this disease.

Sincerely,

Dr. Geoffrey Gotto, BSc(Hons), MD, MPH, FRCSC
Urologic Oncologist, The Southern Alberta Institute of Urology
Medical Director, The Clinic for Advanced and Metastatic Prostate Cancer, The Prostate Cancer Centre
Assistant Professor, Surgery and Surgical Oncology, The University of Calgary
Expert Panel Chair, The Canadian Partnership Against Cancer