Dear Dr. Roach: Regarding your recent column about prostate cancer, could you please clarify a statement that has created some concern and confusion for me? The statement is: “Screening begins to have a net benefit after about 10 or 15 years.” About 10 or 15 years after what exactly?
I had surgery about 18 months ago at the age of 65, and I’m very lucky not to have incontinence or erectile dysfunction, thanks to the nerve-sparing surgery. My cancer was quite aggressive, but was contained. However, I am still quite anxious about metastasis, so this statement leaves me with some doubts about the long-term success of the surgery. My father passed away because of this disease, so you can understand my apprehension.
And by the way, I don’t think that incontinence and erectile incontinence are as common today as you imply, thanks to improved surgical techniques. I worry that some men who should have surgery will decline it based on this statement.
J.W.
Men who undergo screening (by definition, looking for a disease when there are no symptoms) are going to feel worse, even seeing a decrease in their life expectancy during the short term after screening (by getting a PSA test, for example). This is because many men will undergo treatment that has some risks, even if the risks are limited. About one in 200 men who undergo a nerve-sparing radical prostatectomy will die within 30 days of the surgery. Those are pretty good odds, but short-term harm is still done to the group of men who choose screening.
Over time, men will live longer if they have surgery to remove the cancer, but 10-15 years pass before the men who had surgery do better than the men who didn’t know that they had prostate cancer. Prostate cancer is usually very slow-growing. In cases where men are nearing the end of their lives, whether it’s because of extreme old age or because of other serious medical illnesses, it really is better not to look.
However, this is not the case with healthy men. Very careful studies have proven that average-risk men between the ages of 50-70 will have a mortality benefit with prostate cancer screenings because they will live long enough to enjoy the benefit of not having prostate cancer. Whether it’s due to family history (like you) or a specific gene mutation (such as Lynch syndrome or the BRCA family), higher-risk men and Black men should start screenings earlier, usually between the ages of 40-45. Some very healthy men still benefit from screening until an older age, but the data show that more men above the age of 77 will be harmed by screening than those who will benefit from it.
As far as outcomes go, the data are clear: Fifty-nine percent of men will have sexual problems two months after a nerve-sparing radical prostatectomy. Over time, some improve, with 43% having problems two years after the procedure. Similarly, incontinence is a big problem right after surgery. Fifty-two percent of men reported leakage two months after surgery, while 15% still have leakage two years after surgery. These data are from 2022.
My goal is not to cause men to decline a necessary surgery, but I certainly try to reduce unnecessary surgeries. The vast majority of men diagnosed with prostate cancer have a slow-growing form that does not require surgery. Surgery should be reserved for the less-common, more-aggressive prostate cancers, after a thorough evaluation including imaging, a biopsy, and possible genetic testing.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
