Actor Ben Stiller was as surprised as anyone when he heard these words: “So yeah, it’s cancer.”
After all, he was only 48 and had no real reason to suspect that he had cancer, especially prostate cancer, which many people think of as an older man’s disease.
“I have no history of prostate cancer in my family and I’m not in the high-risk group,” he wrote in a public posting detailing his experience. “I had no symptoms.”
So how did the star of movies including There’s Something About Mary, Meet the Parents, and Zoolander end up getting diagnosed in the first place? And what does his case have to say about the way we diagnose and treat prostate cancer in the United States?
Stiller’s story began two years before the day in June 2014 when he was diagnosed with prostate cancer. This is when his doctor, a “thoughtful internist”, gave him a simple and inexpensive PSA screening test. This was the first of many PSA tests over the next few years.
A one-time modest elevation of PSA blood levels can be explained by several factors that are often correctable. So the best course of action is to have follow-up PSA tests to monitor what direction the PSA is moving in.
As follow-up PSA tests were performed, Ben Stiller’s doctor noted a gradual rise in Stiller’s PSA over his earlier baseline. These rising levels triggered a referral to a urologist, who did further testing, including a digital rectal exam, an MRI, and finally a biopsy that confirmed the diagnosis.
Three months after his diagnosis, Stiller had undergone treatment—in his case a robotic-assisted laparoscopic radical prostatectomy, or removal of his prostate gland during a minimally invasive surgery—and was cancer free. That could have been the end of it, but after doing his research into prostate cancer screening and diagnosis, Stiller realized he couldn’t be silent about his experience. He’s been spreading the same message ever since: “Taking the PSA test saved my life.”
This might not seem like a controversial statement—after all, it might seem hard to argue against a simple blood test that can identify prostate cancer early enough to treat it before it spreads and without major side effects. But in fact, due to recent chaos in the official recommendations for PSA blood testing, tens of thousands of American men are skipping the very test that possibly saved Stiller’s life on the advice of their doctors and with potentially devastating consequences.
History of Screening Recommendations
The PSA test is used to measure prostate-specific antigen, a protein that is produced by the prostate gland.
PSA levels rise in aging men and can be the first signal of underlying prostate cancer. So the PSA blood test is used to identify men who may have prostate malignancy and need further evaluation.
This simple blood test was approved by the FDA in 1994, allowing men to begin monitoring their PSA levels and identify possible tumors long before they become dangerous.1
Since PSA testing was introduced, the risk of dying from prostate cancer among men who were regularly screened declined by as much as 42%.2,3
Despite this drop, widespread PSA screening remained controversial in the medical community.
Prostate cancer is typically a slow-growing cancer, and the current biopsy and treatment methods, including the kind of less-invasive surgical removal that Stiller underwent, carry risks such as pain, incontinence and impotence. Some doctors worried that the PSA test, which can detect very slight increases in PSA levels, might be causing men with low-risk cancers to undergo biopsies and possibly unnecessary treatment.
Based on these concerns, in 2012, the US Preventive Service Task Force (USPSTF) issued a stunning update to prostate screening recommendations. Drawing its conclusions from the results of a $400 million federal study, the USPSTF advised against PSA screening for healthy men, saying that PSA screening has “no net benefit.”4-6 The American Cancer Society soon revised its recommendations, steering healthy, average-risk men away from PSA screening until age 50, with revised recommendations for men with a family history of prostate cancer.7
These guidelines caused immediate uproar in the medical community, including rebuttals from Life Extension® urging men over age 40 to continue having annual PSA blood tests. By 2016, the USPSTF announced it was reconsidering its prior recommendations against PSA screening.
In 2017, a new draft recommendation was released for public input. This time, the USPSTF slightly backtracked, saying that the risks and benefits of PSA screening are “closely balanced” in men between the ages of 55 and 69 and they should seek their doctor’s advice on PSA screening. Men aged 54 and under and those over the age of 70 would still be counseled to avoid PSA screening. These new, slightly softer guidelines were still not finalized as of May 2017, and the agency was soliciting public input.8
In Stiller’s case, following even the updated guidelines might have meant disaster—he was still too young to be screened according to the USPSTF (United States Preventive Service Task Force).
“If he [Ben Stiller’s doctor] had waited, as the American Cancer Society recommends, until I was 50, I would not have known I had a growing tumor until two years after I got treated,” he wrote. “If he [Ben Stiller’s doctor] had followed the US Preventive Service Task Force guidelines, I would never have gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.”
The USPSTF’s original recommendations against screening were partly based on the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. This huge trial assigned 76,685 men aged 55 – 74 years to one of two study arms. The first group (38,340 men) underwent annual PSA testing for 6 years and an annual digital rectal exam for 4 years. The control group (38,345 men) underwent normal care, with occasional “opportunistic screening” but no regular PSA monitoring. At the end of the 13-year follow-up period, researchers announced there was “no evidence of a mortality benefit” for annual PSA screening.9 The USPSTF recommendation against PSA screening soon followed.
Life Extension, which has long supported PSA screening, issued a detailed rebuttal challenging the findings of this study. In fact, the study was deeply flawed thanks to widespread “contamination” of the control arm.
While Life Extension was early in identifying the obvious flaws with this study, it wasn’t long until astute research groups began to catch up. In early 2016, a group of urologists from the New York Presbyterian Hospital and Weill Cornell Medical College in New York published a letter in the New England Journal of Medicine confirming what Life Extension suspected.10
The shocking truth was that more than 80% of the men in the control group—which was supposed to only receive “occasional” PSA screening—reported at least one PSA test during the trial. In fact, by some measures, the men in the control group received more PSA screening than men in the PSA screeningarm!10
Their conclusion? “We’re going to have to reconsider this issue.”11
Further support for this position was published in another large study, this one called the European Randomized Study of Screening for Prostate Cancer. This study randomized 182,000 men aged 50 to 74 to a “usual care” control group or a group with PSA screening every two to seven years. Spread across seven research centers in Europe, the group tracked prostate cancer mortality in both study arms. At the median follow-up of nine years, researchers reported that PSA screening resulted in a 20% reduction in prostate cancer mortality!12
A study from the Göteborg center, one of the seven participating centers in this study, found that men aged 50 to 64 years of age who had a PSA screening every other year had a 44% reduced mortality risk from prostate cancer. The center used a PSA cutoff of 2.5 ng/mL to 3.0 ng/mL. Men with these cutoff PSA levels and higher were referred for additional testing, including a digital rectal exam, transrectal ultrasound, and prostate biopsy.13
Although it’s too late to help the tens of thousands of men who likely skipped PSA screening, we are grateful the USPSTF is slowly grappling with the well-documented issues in its original guidelines by issuing the new draft recommendations.14
The issue was further complicated by results from a study published in the New England Journal of Medicinein 2016. This trial followed 1,643 men for a decade, each with prostate cancer that was first detected by PSA screening, to see which of the most popular treatment techniques was most effective, including “active waiting” and monitoring the disease, surgery to remove the prostate gland, or external radiation beam therapy to treat the cancer. While the prostate-cancer-specific survival rate was high (>98%) in all three groups, researchers found that men in the “active waiting” group were more likely to progress to metastatic disease, and about half of them needed surgery or radiation therapy within the 10-year study period.15
These results suggest that men benefit from early detection and early treatment of prostate cancer.
Please note that Life Extension does not recommend “watchful or active waiting” in the presence of high PSA and/or low-grade prostate cancer. We instead advise men to follow an aggressive “active surveillance” program that involves an anticancer diet along with specific drugs and nutrients that may enable early-stage disease to be contained.
Rise in Metastatic Cancer Rates
While various agencies continue to issue contradictory and confusing advice, men across the country have paid the price. In late 2016, a research group from Northwestern Medicine released a stunning and tragic finding: diagnoses of metastatic prostate cancer, the worst type, climbed an unbelievable 72% between 2004 and 2013.16
To reach these findings, the group studied a database of more than three-quarters of a million men in the National Cancer Data Base. What they found should alarm any man who skips his PSA screening.
“The fact that men in 2013 who presented with metastatic disease had much higher PSAs than similar men in 2004 hints that more aggressive disease is on the rise,”17 said study author Dr. Edward Schaeffer, chair of urology at Northwestern University Feinberg School of Medicine and Northwestern Medicine.
“One hypothesis is the disease has become more aggressive, regardless of the change in screening,” said Dr. Schaeffer. “The other idea is since screening guidelines have become more lax, when men do get diagnosed, it’s at a more advanced stage of disease. Probably both are true. We don’t know for sure but this is the focus of our current work.”17
This makes treatment more difficult, and it’s exactly the situation Ben Stiller would have faced if his forward-thinking doctor hadn’t established a PSA baseline early on and tracked it, allowing him to discover Stiller’s troubling increase in PSA levels over time and recommend the movie star for further evaluation and surgery.
It’s important to note that the increase in metastatic, aggressive prostate cancer almost perfectly aligns with the trend away from PSA screening that culminated with the USPSTF 2012 recommendation against any PSA screening.
Prostate Cancer Survivors Due to Early Detection
|Name||Year Successfully Treated|
|Robert De Niro||2003 at age 60|
|John Kerry||2003 at age 60|
|Rudy Giuliani||2000 at age 56|
|Robert Goulet||1993 at age 60|
|Colin Powell||2003 at age 66|
|Michael Milken||1993 at age 46|
Stiller’s Happy Ending
The main concern with PSA screening is the potential for overdiagnosis and unnecessary treatment. These are real concerns—PSA screening frequently returns “false positives,” which are stressful for the patients involved and result in unnecessary biopsies and additional tests.18
We recommends regular, inexpensive PSA screening to establish a baseline and follow PSA numbers over time. If your PSA level rises above 1.0 ng/mL, there are natural and safe measures you can take to reduce it. Further evaluation may be necessary if your PSA continues to rise over time.
In fact, this is exactly the course Stiller followed, and today he’s alive and grateful for it.
“The bottom line for me: I was lucky enough to have a doctor who gave me what they call a ‘baseline’ PSA test when I was about 46,” he wrote in Medium, a popular blogging platform. “My doctor watched my PSA tests rise for over a year and a half, testing me every six months…I think men over the age of 40 should have the opportunity to discuss the test with their doctor and learn about it, so they can have the chance to be screened.”19
More recently, two years after his diagnosis and treatment, Stiller went public with his experience with an interview with Matt Lauer on the Today show, alongside Dr. Schaeffer. While reporting that he wasn’t experiencing any of the major complications of prostate surgery, Stiller gave a simple reason for going public. He wanted to educate as many men as possible about their options when it came to PSA screening.
“It’s a whole new world,” Stiller said. “You need to educate yourself.”
We at Life Extension commend Bernard M. Kruger, M.D. for having the foresight to test Ben Stiller’s PSA blood levels despite conventional “authorities” advising against PSA screening.
Written By Jon Vanzile
Article Source: http://www.lifeextension.com/Magazine/2017/9/Ben-Stiller-Advocates-Prostate-Cancer-Screening/Page-01
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