Prostate Cancer — The Problem of Overdiagnosis, Active Surveillance, and Correct Interpretation of PSA

THE MAIN POINT THAT DISTINGUISHES PROSTATE CANCER FROM OTHER CANCERS AND DETERMINES ALL MANAGEMENT DECISIONS | IN MANY OTHER CANCERS, the earlier the diagnosis, the better the outcome, and this principle is indisputable | IN PROSTATE CANCER, THE SITUATION IS MORE COMPLEX: a SIGNIFICANT PORTION of these cancers remain SILENT FOR YEARS OR EVEN DECADES and DO NOT AFFECT THE PATIENT'S LIFE | It is common in autopsies of elderly men to FIND UNKNOWN PROSTATE CANCER; these individuals DIED NOT BECAUSE OF THEIR CANCER BUT FOR OTHER REASONS | DETECTING AND TREATING THESE CANCERS DOES NOT EXTEND THE PATIENT'S LIFE, but IMPOSES THE PERMANENT SIDE EFFECTS OF SURGERY AND RADIATION THERAPY: URINARY INCONTINENCE | SEXUAL DYSFUNCTION | RULE: the decision should be based not on the question 'IS THERE CANCER' but on 'WILL THIS CANCER HARM THIS PATIENT' | Risk classification SHOULD BE CONFIRMED BY INSTITUTIONAL PROTOCOL

Understanding the problem of overdiagnosis and overtreatment is the key point that distinguishes prostate cancer from other cancers. In other cancers, early diagnosis is indisputably beneficial; in prostate cancer, the situation is more complex because a significant portion of these cancers remain silent for years and do not affect the patient's life. It is common to find unknown prostate cancer in autopsies of elderly men, and these individuals died of other reasons. Treating these cancers does not extend life but imposes permanent side effects such as urinary incontinence and sexual dysfunction. The decision should be based not on the presence of cancer but on whether that cancer will harm that patient.

THE NEED FOR A SHARED DECISION FOR PSA SCREENING MAKES IT INAPPROPRIATE TO ADD THIS TEST TO ROUTINE BLOOD TESTS | IN PRACTICE, PSA is often added to a BLOOD SAMPLE TAKEN FOR ANOTHER PURPOSE or requested as PART OF A GENERAL CHECK-UP PACKAGE → the patient DOES NOT KNOW WHAT THIS TEST MEANS and WHEN THE RESULT IS HIGH, THE CHAIN STARTS | EACH LINK OF THE CHAIN ADDS A BURDEN TO THE PATIENT: BIOPSY — RISK OF BLEEDING AND INFECTION | DIAGNOSIS — the patient BECOMES A CANCER PATIENT and BEARS THIS PSYCHOLOGICAL BURDEN | TREATMENT — PERMANENT SIDE EFFECTS | HOWEVER, SOME PATIENTS MIGHT NOT HAVE WANTED THIS CHAIN FROM THE BEGINNING → the test SHOULD BE DISCUSSED BEFORE REQUESTED, POSSIBLE BENEFITS AND HARMS EXPLAINED, PATIENT'S EXPECTED LIFESPAN TAKEN INTO ACCOUNT | SCREENING DOES NOT PROVIDE BENEFIT IN patients with LIMITED LIFE EXPECTANCY | NON-CANCEROUS REASONS FOR ELEVATED PSA — knowing them PREVENTS A SIGNIFICANT PORTION OF UNNECESSARY BIOPSIES: the marker IS SPECIFIC TO PROSTATE TISSUE but NOT SPECIFIC TO CANCER | BENIGN PROSTATIC HYPERPLASIA (most common) | PROSTATITIS (causes significant elevation; recedes after treatment) | URINARY TRACT INFECTION | CATHETER AND UROLOGICAL INTERVENTIONS | TWO LESS KNOWN REASONS: BICYCLING and RECENT EJACULATION → QUESTIONS THAT NEED TO BE ASKED BEFORE MEASUREMENT exist | REVERSE DIRECTION TRAP: SOME DRUGS USED FOR BENIGN PROSTATIC HYPERPLASIA LOWER PSA VALUE, making the measured value SEEM SAFER THAN IT IS in these patients → DRUG HISTORY IS ASKED | DECISIONS ARE NOT MADE BASED ON A SINGLE HIGH VALUE

The need for a shared decision in PSA screening makes adding this test to routine panels inappropriate. In practice, PSA is added to the general check-up package, the patient does not know its meaning, and when the result is high, the chain begins; each link of the chain imposes a burden, and some patients might not have wanted this from the start. The test should be discussed before being requested, and expected lifespan should be considered. Non-cancer causes of elevated PSA must be known: prostate enlargement, prostatitis, urinary tract infection, catheter and interventions, as well as the less known causes of bicycling and recent ejaculation. Some prostate medications lower the value in the opposite direction, misleadingly showing it as safe.

EXPLAINING ACTIVE SURVEILLANCE TO THE PATIENT CORRECTLY DIRECTLY DETERMINES THE SUCCESS OF THIS OPTION; IF EXPLAINED INCORRECTLY, THE PATIENT LEAVES THE PROGRAM | PATIENT'S PERSPECTIVE: they have been DIAGNOSED WITH CANCER and their DOCTOR IS NOT STARTING ANY TREATMENT → this is EASILY INTERPRETED as being NEGLECTED or ABANDONED | RESULT: the patient becomes ANXIOUS | THE FAMILY APPLIES PRESSURE | FREQUENTLY SEEKS TREATMENT AT ANOTHER CENTER | HOWEVER, ACTIVE SURVEILLANCE IS NOT AN ABSENCE BUT A PROGRAM: REGULAR INTERVAL PSA MEASUREMENT | EXAMINATION | IMAGING | REPEATED TISSUE SAMPLING | WHEN A SIGN OF DISEASE PROGRESSION IS DETECTED, TREATMENT IS INITIATED | IN OTHER WORDS, THE PATIENT IS NOT UNMONITORED, ON THE CONTRARY, CLOSELY MONITORED | WHEN THIS DISTINCTION IS CLEARLY EXPLAINED and THE SURVEILLANCE SCHEDULE IS GIVEN TO THE PATIENT IN WRITING, ADHERENCE INCREASES SIGNIFICANTLY | RISK STRATIFICATION DETERMINES THE TREATMENT DECISION — two patients with the same diagnosis are MANAGED COMPLETELY DIFFERENTLY IF THEIR RISK GROUPS ARE DIFFERENT, and IF THIS DIFFERENCE IS NOT EXPLAINED, it CREATES CONFUSION: the patient HEARS THAT ANOTHER PROSTATE CANCER PATIENT IN THEIR ENVIRONMENT UNDERWENT SURGERY and ASKS WHY THE SAME THING WAS NOT DONE FOR THEM | INFORMATION USED TOGETHER IN STRATIFICATION: BIOMARKER LEVEL IN BLOOD | EXTENT OF THE TUMOR IN TISSUE EXAMINATION SEEMS AGGRESSIVE | HOW MUCH SPACE THE TUMOR OCCUPIES WITHIN THE PROSTATE | IMAGING FINDINGS | In addition, THE PATIENT ALSO PARTICIPATES IN THE DECISION: AGE, OTHER DISEASES, and PREFERENCE REGARDING SIDE EFFECTS | THE DECISION IS BASED NOT ON A SINGLE NUMBER BUT ON THE WHOLE

Correctly explaining active surveillance determines the success of this option. From the patient's perspective, they have been diagnosed with cancer and no treatment has been started; this is interpreted as neglect, their family puts pressure on them, and they often seek treatment at another center. However, active surveillance is not an absence of action but a program: it includes planned measurements, examinations, imaging, and repeated tissue sampling, and treatment is initiated when progression is detected, meaning the patient is closely monitored. When this distinction is clearly explained and a schedule is provided in writing, adherence increases. Risk classification determines the treatment decision, and if it is not explained, the patient may hear that someone else has had surgery and ask why it was not done for them; the decision is based on the whole, not on a single number.

SIDE EFFECT BURDEN OF HORMONE-SUPPRESSING THERAPY — the area that determines quality of life and is OFTEN NEGLECTED | The treatment works by SUPPRESSING THE MALE HORMONE and this suppression AFFECTS MANY SYSTEMS OF THE BODY | BONE DENSITY DECREASES and FRACTURE RISK INCREASES — THIS PROCESS IS SILENT AND GOES UNNOTICED UNTIL A FRACTURE OCCURS | BODY COMPOSITION CHANGES: MUSCLE MASS DECREASES, FAT INCREASES and SUGAR LEVEL MAY INCREASE | CARDIOVASCULAR RISK INCREASES | HOT FLASHES DISTURB DAILY LIFE, BUT PATIENTS MAY HESITATE TO DESCRIBE IT AS A COMPLAINT THAT IS NOT SPECIFIC TO MEN | LOSS OF SEXUAL FUNCTION and MENTAL EFFECTS are also DIFFICULT TOPICS TO TALK ABOUT | RULE: SIDE EFFECTS ARE ASKED DIRECTLY AND INDIVIDUALLY; EXERCISE IS PLANNED FROM THE BEGINNING WITH BONE PROTECTION | SPINAL CORD COMPRESSION — THE MOST CRITICAL URGENT DECISION THAT PREVENTS PERMANENT DISABILITY: THIS CANCER MOST OFTEN SPREADS TO THE BONE AND ESPECIALLY TO THE SPINE; When a focus in the spine grows, it can COMPRESS THE SPINAL CORD | THE INSIDIOUS SIDE OF THE PROCESS: THE FIRST SYMPTOM IS BACK PAIN and THIS COMPLAINT IS EXTREMELY COMMON IN THIS AGE GROUP → when the patient presents with back pain, A MECHANICAL CAUSE IS CONSIDERED, PAINKILLERS ARE GIVEN and FOLLOW-UP IS RECOMMENDED | HOWEVER, IN A PATIENT WITH KNOWN PROSTATE CANCER, BACK PAIN THAT HAS JUST STARTED OR CHANGED IN NATURE IS HANDLED WITH A DIFFERENT WEIGHT | When WEAKNESS, NUMBNESS IN THE LEGS or URINARY INCONTINENCE are added to the pain, the picture is URGENT: HOURS ARE IMPORTANT AT THIS STAGE BECAUSE NERVE DAMAGE DOES NOT RETURN AFTER A CERTAIN POINT

The burden of side effects of hormone-suppressing therapy determines quality of life and is often neglected. Bone density decreases and this process is silent, not noticeable until a fracture occurs; body composition changes, sugar may rise and cardiovascular risk increases. Hot flashes, loss of sexual function and mental effects are difficult topics to talk about and the patient is hesitant to tell, so they should be asked directly and individually. Spinal cord compression is the most critical emergency decision; The first finding is back pain and is considered mechanical because it is very common in this age group. In known prostate cancer, new or changing back pain should be handled differently; When weakness or urinary incontinence is added, hours count.