By Dr. CHRISTOPHER J. MORGAN
For the past three years, as part of my annual physical examination, I have a digital rectal examination (DRE) of my prostate. Although I do not have a close family history of prostate cancer and I am trying my best to lead a healthy lifestyle, I and my family physician, who is also a member of the Black community, are aware that Black (people of African descent) men are at increased risk of developing prostate cancer. Like anyone, I would like to live a long, fruitful and healthy life. That means, among many other things, being proactive concerning my health and well-being.
My next annual physical will be early in the New Year. Since my last physical I have been thinking about discussing with my family physician the inclusion of a Prostate Specific Antigen (PSA) test, along with the DRE, to my overall prostate health screen and examination. According to Prostate Cancer Canada, annual prostate cancer deaths compares with breast cancer deaths, taking 4,000 lives each year. According to the Canadian Urological Association, a Canadian male has a one in seven chance of being diagnosed with prostate cancer and a one in 27 chance of dying from it. It is the third leading cause of cancer death in men in Canada.
Interestingly, on the eve of the Movember Campaign a month ago to increase awareness and raise funds for prostate cancer and men’s health, a rather controversial announcement was made regarding the value of PSA testing. Recommendations by the Canadian Task Force on Preventative Health Care (CTFPHC) suggest that PSA testing is not beneficial and should not be used as a screening tool.
Some of the arguments for getting rid of PSA testing site the high rate of false positives. A false positive occurs with an elevated PSA score from a prostate which is not actually cancerous. False positives can lead to unnecessary biopsies and worse, surgery or radiation which can have negative side effects on bladder and/or sexual function. Another argument is that in many cases of prostate cancer the cells are slow growing, such that men will die with prostate cancer as opposed to dying from prostate cancer.
Not everyone agrees with the CTFPHC recommendations. Rocco Rossi, President of Prostate Cancer Canada, argues that since clinical PSA testing started in the 1990s, prostate cancer mortality (death rate) has declined by over 40 per cent. Rossi believes eliminating the test would “result in 800-1000 additional men dying every year without that early detection”.
He also highlights that in Ontario over 50 per cent of the men diagnosed with early stage prostate cancer are under “Active Surveillance”, which means they are being monitored closely to determine how slow growing or aggressive the cancer cells are behaving. This helps to better match treatment options like surgery or radiation, only where and when it is most needed.
The Canadian Urological Association (CUA) also has its reservations about the CTFPHC recommendations, noting that the group did not consistently come to its conclusions using the strongest level research. The CUA is aware of PSA testing imperfections but continues to recommend its use as a screening tool. In their own guidelines, CUA recommends PSA testing starting at age 50, but advocate for screening as early as 40 for high-risk men, men with a family history of prostate cancer or of African descent. They recommend annual PSA testing to observe rate of change over time. They also endorse Active Surveillance to minimize over treatment and they encourage a healthy, well informed discussion between physicians and patients on risks, treatment options and outcomes.
Before I book my annual physical I wanted to hear from a prostate cancer survivor. Winston Isaac was diagnosed with prostate cancer in 2002. Following his journey with prostate cancer he founded the Walnut Foundation, a prostate cancer and men’s health support group. I have known and worked with Winston for a number of years and thought we would benefit from his perspective on the topic.
How was your diagnosis of prostate cancer made, and was a PSA test a part of that process?
The Prostate Specific Antigen (PSA) test played a large part in alerting me that there was a reason to be concerned about my prostate health. There was an annual reading that was increased over the reading of the previous year by an increment that was considered significant. Without the PSA test, the condition would have gone undetected as there were no “real” symptoms. After, the alert from the PSA, other diagnostic procedures followed, including a biopsy which showed the presence of very active cancer cells. The good news in my situation is that the diagnosis was made early and I had a choice of treatment options.
Recent recommendations by the Canadian Task Force on Preventative Health Care (CTFPHC) suggest PSA testing for Prostate Cancer is not beneficial and are recommending that PSA screening not be performed for prostate cancer. What are your thoughts regarding these findings?
Their findings although provided with the facade of being “scientific” are a disservice to men. The Task Force should have recommended that physicians be better prepared for understanding the application of the results of the PSA test rather than suggesting that the test is useless. The test is a good one but needs to be applied with a basic knowledge level. Any test can be considered useless if the person who is applying the results does not understand how to do so. It may interest you to know that the Task Force members were not physicians and/or urologists and/or oncologists. There was no “value” proposition applied when making the recommendation. The PSA test is of value to any man whose diagnostic journey was triggered by the PSA test.
Has the CTFPHC recommendations generated discussion among the membership of The Walnut Foundation?
We dedicated part of our September monthly meeting to the discussion around the effective use of the PSA test and that guys, especially in the Black community, should still be asking their family doctor to order it and, moreso, if they have not had a baseline PSA reading done and if there is a family history of prostate cancer.
If Black (people of African and Caribbean descent) men are at increased risk of developing prostate cancer and if they are hesitant or reluctant to have the digital rectal exam, in the absence of PSA testing could Black men be put at even greater risk?
Without the PSA and the reluctance of Black men to agree to the Digital Rectal Examination (DRE) there will be an increased incidence of prostate cancer in the Black community. Not only will there be an increased risk of developing prostate cancer but there will be a great chance that the presence of prostate cancer will be found in the later stages, when there may be damage beyond the prostate. When there is damage beyond the prostate, the treatment choices are lessened and the negative outcomes (such as incontinence and erectile dysfunction) are greater.
What public policy recommendations do you believe should be in place to improve how we educate, screen and manage prostate cancer?
Healthcare authorities need to ignore the recommendations from the Canadian Preventative Health Task Force and continue to recommend PSA testing especially for vulnerable groups such as Blacks.
The Ministry of Health and Long Term Care needs to fund PSA testing both for screening and monitoring purposes.
Family physicians and other frontline Healthcare providers in men’s health need to be properly informed of the benefits of PSA testing and how to carefully apply the results of the test.
There is a need for more public service announcements and awareness activities targeted to vulnerable groups about prostate cancer.
Community groups such as the Walnut Foundation, with an interest in prostate cancer awareness, need to be recognized by government as an important contributor to health promotion and disease prevention.
What activities are you and the Walnut Foundation planning for the coming months and New Year?
The Men’s Health Interest Group and the Prostate Cancer Support Group of the Walnut Foundation will continue with their monthly information sessions on the second Sunday of the month.
We are currently planning for our annual symposium for February 7, 2015 at Century Gardens in Brampton. This year’s symposium topic will be mental health. This is a free event.
We continue to collaborate with community groups to bring the messages about prostate cancer awareness and men taking responsibility for their health.
Our Annual Conference on Men’s Health will be held on November 7, 2015 at Ryerson University in Toronto.
For more information about The Walnut Foundation please contact Winston Isaac at 905-799-2759, email at firstname.lastname@example.org or email@example.com, or visit online at www.thewalnutfoundation.com and follow us on Facebook at www.facebook.com/thewalnutfoundation.
Dr. Christopher J. Morgan is the director of Morgan Chiropractic & Wellness, an interdisciplinary health centre in Toronto, and the Founder and Past President of the Black Health Alliance, a network of community organizations, health professionals and community members working in partnership to advance the health and well-being of the Black community. He can be reached at 416-447-7600 or firstname.lastname@example.org.