Cancer death rates are going down. Is prostate cancer an exception?

Feb. 4--In a time of declining death rates from cancer, prostate cancer is something of an outlier.

The American Cancer Society last month reported a 2.2% decline in the cancer death rate in 2017, although it gave most of the credit to a drop in lung cancer deaths tied to a continued decline in smoking.

But a nonprofit called Zero cancer, which focuses specifically on seeking an end to prostate cancer, discovered troubling news, also from American Cancer Society data. The report projects that in 2020, the number of men who die from prostate cancer in the U.S. will be at the highest level in two decades. It will represent a 5% increase in a single year, according to Zero's news release.

"These statistics are unacceptable and show the urgency for men to get tested early, given the high likelihood of men developing prostate cancer during their lifetime," said Zero CEO Jamie Bearse in the news release.

But two Minnesota cancer experts the News Tribune spoke with for this story took a more nuanced view.

"I don't know that there's some hidden epidemic of prostate cancer that we're missing," said Dr. Charles Ryan, an oncologist at the University of Minnesota Medical School for whom prostate cancer is a top research area.

The figures for 2020 are speculative, of course. "We don't know the number," Ryan said. "They're still estimates, and we don't have the actual number."

Ryan said there are other factors to consider. Dr. Daniel Nikcevich, an Essentia Health oncologist who also is president of Duluth Clinic and was interviewed separately, agreed.

For one thing, Ryan said, a wave of baby boomers is entering their 70s, which is prime age for prostate cancer. Also, fewer people are dying of heart diseases in their 50s and 60s, which means more men are living to an age when prostate cancer is more of a risk.

Nikcevich and Ryan both pointed to changes in the use of prostate cancer screening as a factor. In 2012, the U.S. Preventive Services Task Force issued an advisory discouraging PSA screening. Falsely elevated readings sometimes led to unnecessary medical treatment and traumatized men, the task force found. In short, it concluded that PSA tests were doing more harm than good.

The task force has since walked back that recommendation, Ryan said, but it created enough confusion that many primary care physicians have stopped doing the screenings.

The problem is that more lethal forms of prostate cancer aren't being detected as soon as they used to be, Nikcevich said. And that reduces the chances of successful treatment.

"The pendulum has swung the other way, where under-treatment has happened as the screening is not happening to the same extent it happened before," he said. "And now men are coming to our attention with symptomatic advanced prostate cancer, and we would think if we had known about that two years ago, this would have been a different issue."

There's an excellent chance of curing any form of prostate cancer if it's caught early, Nikcevich said.

A large study by Kaiser Permanente researchers in northern California found that for every 25 prostate cancer missed by lack of screening but found later, one was metastatic, meaning it had spread beyond the prostate. The study was published in December in the Journal of General Internal Medicine.

The Zero organization is bullish on PSA tests.

"Early detection saves lives, but unfortunately, decades of mixed messaging about the PSA test have left both doctors and men confused about the importance of testing," Bearse said in the news release.

The conventional thinking, Ryan said, is that men should have a PSA screening beginning at age 50, but at age 40 if there's a concerning family history or other reason to suspect a greater risk of prostate cancer. That should be a discussion between the patient and his doctor, he said.

Nikcevich emphasized the importance of that conversation about whether to screen or not to screen.

"And unfortunately, I think what's happened too often is that it's just not done, and that conversation doesn't necessarily occur," he said. "And there's a variety of reasons for that, ranging from perhaps misinterpretation of the guidelines to patients not wanting to be screened to physicians not having time to do the screening."

More benign forms of prostate cancer can be observed without necessarily requiring any form of treatment, Nikcevich said. When treatment is necessary, it has improved greatly in recent years. Both surgery and radiation treatment for prostate cancer have become far more precise, he said. Surgery is almost always done robotically now.

"And there's far less discomfort and pain in that regard,and I believe quicker post-operative recoveries," Nikcevich said.

If some form of treatment for your prostate cancer is recommended, ask if there are any clinical trials available, he advised.

If you're in a clinical trial, you'll receive the top current standard of care plus a new form of therapy that otherwise would be unobtainable, Nikcevich said. You're also helping to pave the way on behalf of other cancer patients down the road.

Men who want to better protect themselves from prostate cancer should know their family history, discuss screening with their doctor and live a healthy lifestyle, Ryan said.

That includes exercise, eating more salmon and fatty fishes, using healthy oils such as olive oils and eating healthy nuts such as almonds. It also means cutting down on processed meats and well-cooked red meats. Even drinking coffee can provide some protection against prostate cancer, he said.

Men should be attuned to their bodies, Nikcevich said. Symptoms that could suggest a problem include a change in your ability to initiate a stream of urine, leakage of urine, pain with urination, blood in the urine and sometimes sexual dysfunction.

"These are not easy subjects for men to talk about," he acknowledged.

So much so that the doctor often needs an ally.

"You see a guy in the office and ultimately, why is he there?" Nikcevich asked rhetorically. "He's there because his wife told him he had to be there, and he's sick of hearing about it."

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