The need for this editorial was triggered by a growing observation in our outpatient department and also by recent epidemiological studies related to prostate cancer and their media coverage.
A scenario that is getting increasingly frequent in our cancer hospital is that of an otherwise healthy and active elderly man getting a regular health checkup, which, in addition to the routine blood investigation, includes a cancer marker called PSA or Prostate Specific Antigen, a test commonly available in most laboratories across the country.
What happens if PSA result is elevated and out of range?
It doesn’t take much time for a Google-enabled family to gather all the information about the significance of an elevated PSA, including the strong possibility of having prostate cancer.
PSA now transforms to ‘Panic Struck Ahead’ and the anxious family is found in the clinic of a Urologist or Urologic Oncologist, the most obvious step to be taken then.
Some FAQs related to this scenario
Is prostate cancer common in elderly men? Yes. Is the incidence of prostate cancer in India rising? Yes. Does the PSA test help in diagnosing prostate cancer? Yes. Is an elevated PSA test always due to cancer? No. Is every prostate cancer diagnosed because of routine PSA testing life-threatening? No. Does every prostate cancer diagnosed from routine PSA testing warrant treatment? No. While the first three ‘Yes’ are known to most families who visit us with this clinical problem, they are almost never aware of the subsequent three ‘No’.
Prostate cancer has been in the news in our country of late. A few weeks back, the Lancet journal commissioned a detailed report on the concerns of the rising incidence of prostate cancer globally.
While prostate is the commonest cancer in men in the western world, epidemiological trends in India seem to be heading in the same direction. The report highlighted that the incidence of this cancer in Indian men has increased by 30 per cent nationally and by 75-80 per cent in the urban population in the last 25 years. An increasing longevity has been attributed to the rise in incidence of this disease and since there are not many modifiable risk factors, getting prepared to face the increasing burden should be prioritised.
A recent report in this print media highlighted how science and money are coming together in the quest for immortality. Our country has been keeping pace with the global phenomenon of an increase in average longevity. The International Institute of Population Sciences, Mumbai in collaboration with the NPHCE, MoHFW, Harvard T. H. Chan School of Public Health (HSPH) and the University of Southern California (USC), published the Longitudinal Ageing Study in India (LASI) in 2020.
The study reported that the elderly aged 60 and above which accounted for 8.6 per cent of the total Indian population, numbering 103 million is projected to rise to 19.5 per cent (319 million) of the elderly by 2050. Considering our denominator which is second to none now, the absolute number of septa and octogenarians in our country will be many.
Whenever there is a concern of a rising incidence of a particular disease, the human nature is to first rule out if ‘I could be one of them’. While detection of most other cancers in the absence of any symptoms would entail meeting a physician or attending a cancer awareness camp, prostate cancer detection is most commonly done by a simple blood test called Prostate Specific Antigen or PSA, which is routinely performed across thousands of laboratories in our country and does not mandate a doctor’s prescription.
If your next thought is why not perform this simple blood test in all elderly men, that is exactly what the Western world did in the early 90s. Some did use PSA as a tool to screen their male population for prostate cancer in the past. Many other parts of the world decided against its routine use.
The issue of using PSA for mass screening of the population is a complex one and currently without consensus on its merit from a public health standpoint. India does not have a unified policy on whether PSA should be routinely done to screen its population. However, our growing economy has brought an increasing number of laboratories performing routine health checks even in tier-two cities and smaller towns.
The list of investigations in these routine health checks is heterogenous and PSA is a popular inclusion. An aftermath of the recent concerns about this cancer in the media could be an increased utilisation of this simple blood test, either as a part of the health package or on demand by the patients.
An elevated PSA level on a routine health check without a prior information about what it could indicate and a Google search mentioning an abnormal PSA being related to prostate cancer is an obvious recipe for panic.
Cancers have a spectrum. From early stage and less aggressive disease to advanced stage and lethal disease and prostate cancer is no exception to this basic understanding.
Prostate cancer however, has a unique zone where despite having a diagnosis of the dreaded ‘C’ in hand, some of these men may live for years without any treatment. Certain forms of low-risk or more technically ‘indolent’ disease may almost never be lethal for the patient with or without treatment. The chances of diagnosing this form of disease increases with the routine use of PSA testing without any symptoms, a phenomenon known as ‘screen-detected cancer’.
Last year, the reputed New England Journal of Medicine compared the outcome of more than 1600 men diagnosed with early stage prostate cancer following PSA testing. Two-thirds of these men were treated with surgery or radiation therapy and one-third were kept under surveillance and received no active treatment.
After 15 years follow up the study did not find a major difference in the two strategies (treatment or observation) with regard to death due to prostate cancer. This meant that even without any form of treatment men with prostate cancer of early stage and a favorable pathology lived as long as those who were treated actively. Those who were only observed did have a higher chance of disease spread over the years but this did not translate into a poorer survival, possibly because they were salvaged with treatment later. While it would not be possible to discuss more details of the study here, the bottom line is that not every prostate cancer is lethal and not every prostate cancer needs treatment by default.
Men diagnosed with early prostate cancer with specific pathological findings following routine PSA check can take time to understand the risks and benefits of cancer directed treatment and can explore if they would be eligible for a no active treatment option.
The obvious million-dollar question is, if there is a way to find out who has the not so bad cancer and who doesn’t. Tools like the MRI scan have a crucial role here and should ideally be done before the decision to do a biopsy of the prostate gland is made. This step can help avoiding biopsy and the consequent anxiety in many patients. Additionally, there are newer biomarkers that can help in differentiating lethal and non-lethal cancers; however, they are yet to arrive in India. The quest for a more effective sieve is globally on going.
PSA can also be elevated to a certain extent because of non-cancerous causes like infection, very large prostate gland and retention of urine in the bladder and once these causes are addressed the PSA levels decline in many instances. However, these non-cancerous causes would generally not raise the PSA beyond a certain value and finding the cause of raised PSA should best be left in the hands of an expert specialist.
Elderly males should get a PSA test done in consultation with a medical expert, preferably a Urologist. Many elevated PSA levels, depending on their value and other clinical details, may not always be equated with life-threatening cancer and sometimes not even with cancer. I do not suggest that all diagnosed prostate cancers can be considered for observation without any active treatment, but that in carefully selected men with an early prostate cancer, after a thorough evaluation, the option of a regular surveillance can be considered over an active treatment intervention.
Age is the biggest risk factor for most cancers and more so for prostate in men. With our increasing longevity, we should be prepared to see an increase in the incidence of this cancer. As the health system of our country prepares for this likely surge, one should keep in mind that equating every elevated PSA level to a dear family member’s life threat due to prostate cancer is a thought process that could change for our citizens.
(Authored by Dr Gagan Prakash, Professor and Chief, Division of Urologic Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai)
The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.