As the world continues to be affected by the COVID-19 pandemic, severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), prostate cancer awareness may seem like something that could be forgotten this year. Just today in the state where I live, Illinois, we learned of 1,880 new cases of coronavirus yesterday, with over 180,000 deaths in the United States (US) since the pandemic started. Our normal lives have been disrupted, with restaurants and gyms open only with significant restrictions, and church services limited in number or only held online.
Many children are largely distance learning for at least part of the week, and parents again face the struggles of balancing working remotely and trying to support the educational and emotional needs of their children. In the midst of this, despite all that we face, I believe remembering prostate cancer, and continuing to ensure early diagnosis, equal access to care, and optimal outcomes for all men afflicted is more important than ever. Here are five reasons why:
- Prostate cancer is the most commonly diagnosed non-cutaneous cancer in American men. It is estimated that there will be over 190,000 men in the US diagnosed with prostate cancer this year. This number declined sharply when the US Preventative Services Task Force altered screening guidelines in 2012 but has been rising again. The reason for this is that the number of men with prostate cancer didn’t really change. We are just diagnosing it less. In some ways, this can be a good thing as there may be less overdiagnosis in elderly men who have other illnesses that may be more severe than relatively slow-growing prostate cancer. However, the decline in diagnoses was not in elderly men, but rather in younger men who often have more aggressive cases. These men are now being diagnosed, but with more advanced prostate cancer that may be more difficult to treat and less likely to be cured. It is up to us, physicians, loved ones, and men themselves, to talk about screening openly with each other and encourage men to figure out if screening is the right thing for them with their doctors. Missing the chance to diagnose early may be missing a chance for cure. We cannot let embarrassment to talk about prostate cancer or fear of things like COVID-19 stop us from identifying men who have prostate cancer. Only by doing this can we hope to prevent prostate cancer from taking another life.
- Early diagnosis can result in more men being monitored without surgery or radiation, and more men being cured if they need more intensive treatment. Just because men are diagnosed with prostate cancer, does not mean they will need aggressive life-altering treatment. The earlier we identify prostate cancer, the greater the likelihood that the cancer is in an early stage. Most men with low-grade prostate cancer that is only found in the prostate can be monitored and managed through active surveillance programs that follow prostate-specific antigen (PSA) levels and catch the disease if it starts to become more aggressive. Treatment with things like surgery and radiation is only employed when the disease shows that it could harm the patient, and everyone else is monitored with minimally invasive procedures. Stacy Loeb and colleagues reported on the use of active surveillance in the Veterans Affairs health system in 2018, finding that over 40% of men with prostate cancer were successfully monitored and managed with conservative management strategies, saving these men from unnecessary procedures1. To be clear, active surveillance is active – patients must continue to see their physicians to have PSA values checked over time. This is different than watchful waiting in which patients do not have further assessments for their cancer unless symptoms develop from more advanced disease. It also includes the treatment of cancer if it becomes more aggressive. However, treatment of early-stage disease is far more likely to be curative than if the disease was identified later when it may no longer be in a state we can cure. The balance between monitoring and treatment is one that may help even the most hesitant among us to move forward with prostate cancer screening, COVID-19, or not.
- New treatment options make the future bright. I continue to be amazed at the way treatment options for prostate cancer expand. Year after year new treatments are developed and approved, with two new therapies approved in May 2020, and others within our sights. The generosity of the men who enroll in the clinical trials that make this possible cannot be overstated, as they pave the way for others to reap the benefits of new treatments. We are all grateful for their participation and grateful for the treatments that are available when the trials are finished. Seeking out trial options is a key aspect of living with prostate cancer, and I encourage men and their loved ones to ask questions and find trials to consider whenever they can. For each approved drug there are men who were treated before the drug was more broadly available because they chose to get involved with clinical trials. Trials did not stop for COVID-19. Here’s to what we now can do, and to a future filled with even more therapies because of the men and their families who make that possible.
- There are genetic implications for families. In the last few years, it has become increasingly clear that there are heritable cancer syndromes that affect men with prostate cancer and their families. I remember nearly a decade ago when the world learned that Angelina Jolie underwent a double mastectomy, shining a spotlight on BRCA1 and BRCA2 gene mutations that predispose women to breast and ovarian cancer. What was less commonly discussed was that those same genetic mutations also increase the risk of prostate cancer. Men who inherit mutant copies of these genes and others can develop prostate cancer, and their relatives, both women, and men, may have these mutations and be affected, too. Germline genetic testing is now recommended for all men with metastatic prostate cancer to understand whether they inherited and could pass on gene mutations that could affect relatives. Stories about identifying breast cancers with early mammograms in the daughters of prostate cancer patients with BRCA1 or BRCA2 mutations are now nearly as common as finding early prostate cancer in sons, and identifying these families through men with prostate cancer rather than through young women with breast or ovarian cancer is now possible. We must ensure that we test, however, and talk with men and their families about the potential implications of these syndromes. What has always been a family affair has become even more so, and spreading the word and ensuring germline testing is now a cornerstone of care. We cannot let COVID-19 stand in the way of helping men and their families understand these underlying risks for their families.
- Like so many aspects of life, disparities exist in prostate cancer, too. Disparities permeate our lives, and medicine is no exception. Racial disparities exist in diagnoses and outcomes, with Black men being diagnosed more frequently than White men, and being nearly 2.5 times more likely to die of prostate cancer. Research seeking to understand these disparities suggests that rather than biologic differences driving these outcomes, societal pressures and access to cancer care may be the root of the problem2. COVID-19 has the potential to magnify these issues unless we make a concerted effort to counteract it. We must continue screening to identify disease early in all men. We must ensure that men get to their physician teams after a diagnosis quickly, despite fears of possible exposure to COVID-19. We cannot allow the possibility of harm from infection with coronavirus stop people from making a plan for treatment or surveillance, especially in communities comprised of predominantly minority men, men of lower socioeconomic status, and those that are geographically isolated from care. Like the coronavirus, whether young or old, Black or White, rich or poor, prostate cancer can affect us all. Also like the coronavirus, however, some communities have poorer outcomes and are harder hit. We must protect each other in both instances, and recognize that helping others is helping us all.
We are all in this together. Remembering prostate cancer, ensuring that we diagnose it early, in all men who are afflicted, makes the future brighter for all of us. No matter what happens with COVID-19 in terms of a vaccine or improved treatments in the short term, we cannot let coronavirus continue to affect our lives for years to come due to delayed diagnoses and missed opportunities in prostate cancer. Stand with me and the prostate cancer community as we celebrate prostate cancer awareness every September, remembering this deadly disease and doing what we can to stop it. COVID-19 or not, prostate cancer and the men and families affected must never be forgotten. No matter what.
Written by: Alicia Morgans, MD, MPH, Associate Professor of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
References:
Continuing the Momentum with Patient Advocacy - Elisabeth Heath
In His Own Voice: His 15-Year Journey with Advanced Prostate Cancer - Steve Poggi
Study of Baseline PSA Screening of Men (45 years old) - Peter Albers
Genetically Informed Treatment for Advanced and Metastatic Prostate Cancer - Alicia Morgans
The Delivering of Genetic Counseling, Processes and Outcomes, The ProGen Study - Mary-Ellen Taplin
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