this expert says prostate cancer is a normal part of the aging process for men, like 'grey hair and wrinkles.' but there are still barriers to care
dr. neil fleshner, an oncologist and researcher with toronto's university health network, says that although research and new treatments are turning prostate cancer into a chronic illness, over-diagnosis, over-treatment and social inequities remain challenges.
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"if you live long enough, you’re likely to develop some degree of prostate cancer," says dr. neil fleshner. getty
dr. neil fleshner, a leading surgical oncologist and researcher with the university health network (uhn) in toronto has witnessed firsthand the results of advancements in his field: better detection and drug treatments, and minimally invasive techniques when surgery is required.
for people with prostate cancer and their families, his view on how canada’s health-care system has made strides over his two-plus decades on the front line is optimistic. the bottom line for prostate cancer, even in its most aggressive stages, is people are living longer, and he sees that in his clinic followups.
“there truly are miracles,” he says. “when you see people who you were pretty sure would be dead in a year or two or three, and then there they are, six, seven, eight years later and they’re fine, free of cancer. that’s an amazing feeling. to me, it’s celebrating the wins that are the best.”
people are living longer with prostate cancer
his team is leading a major clinical trial, 10 years in the making, with 400 men across the country who have slow-growing prostate cancer. half of the participants are taking a placebo while the other half are taking metformin, a long-established medication for controlling blood sugar levels in people with type 2 diabetes. previous studies have shown that the drug inhibits cancer cell growth.
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“it has to do with the metabolism of prostate cancer and how it metabolizes sugar in a unique way,” fleshner explains. “we’re trying to exploit that biology.”
results of the clinical trial are expected in the coming months.
he says that the diabetes drug has experienced a bit of a rebirth of late, with findings by university of minnesota researchers, whose work was published in lancet infectious diseases, that showed metformin could potentially also cut the risk of developing long covid.
prostate cancer treatment beyond metformin
while radiation, chemotherapy, hormone therapy and surgery are also treatment options, depending on the stage and type of prostate cancer, active monitoring is preferred for low-risk patients. that’s because many prostate cancers tend to grow slowly and cause no symptoms or problems — also no treatment means no serious side effects.
“prostate cancer is in a delicate part of the body, so when you treat prostate cancer, unlike other cancers, there’s a real impact potentially on your quality of life with urination trouble, sexual trouble or bowel trouble,” says fleshner. “that’s the main reason why we don’t want to overtreat patients.”
prostate cancer is a part of aging
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prostate cancer is generally part of the aging process for men, he says, much like “grey hair and wrinkles.” if you live long enough, you’re likely to develop some degree of prostate cancer.
in fact, autopsy studies of people who die of other causes have shown that incidence of prostate cancer starts in the third decade of life and increases 10 per cent each decade. so, 30 per cent of 30-year-olds have cancer in their prostate, as do 80 per cent of 80-year-olds.
and according to the canadian cancer society, prostate cancer affects one in seven canadian men. of those, about three to four per cent will die. and because of its prevalence, fleshner says prostate cancer is the second most common cause of cancer death in men.
over-treatment is a challenge
finding a balance between detection and treatment is important, says fleshner, because early detection of low-risk prostate cancer can cause a lot of unnecessary anxiety, concern and treatment. in fact, there’s some controversy about the potential of over-diagnosis as a result of screening, which involves a prostate specific antigen (psa) test that measures the level of psa in the blood. the concern is that screening can detect the possibility of prostate cancer in men who would never have symptoms or be at risk of death, resulting in unnecessary biopsies that cause pain and increases the risk of infection. subsequent treatment includes surgery and radiation, which can lead to complications like erectile dysfunction and urinary incontinence.
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“[prostate cancer] can be subject to over-treatment and over-detection,” he says. “conversely, if you ignore it totally, then you’re going to have a lot of men dying unnecessarily. not all cases need treatment and some need extremely aggressive treatment.”
in attempt to put guardrails on groups like the canadian urological association have weighed in on guidance for conducting the early testing, suggesting that men be consulted about prostate cancer testing at age 50, and at age 45 for those at higher risk. men are at higher risk if there a history of prostate cancer or other cancers in the family and extended family. and then there’s the link to the brca gene — typically associated with women who have an increased risk of breast or ovarian cancer. those related to a brca gene carrier are also at an increased risk of prostate cancer.
raising awareness of prostate cancer important for communities more at risk
“there are many patients who continue to present way too late because they’re not getting tested early,” says fleshner. “there’s also the issue of reaching some of the less fortunate populations, particularly the black population, which is a subgroup of canadians particularly at high-risk for prostate cancer and aggressive prostate cancer.”
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in an effort to address this disparity, he has a research team working with the walnut foundation charity, a support group for black males with prostate cancer, to engage those men in the health-care system so they can avoid advanced disease. and though patient self-advocacy and empowerment through information and support services remains a challenge, fleshner says there is plenty to be hopeful about.
“the reality is that most men who are going to even be diagnosed will not die of their disease, so i think that’s a huge piece of hope,” he says. “and secondly, for those unfortunate men who do have more advanced disease, there is a better outcome than in the past as it becomes a chronic illness. i think that’s something that really should be encouraging.”
for more information on prostate cancer, visit prostate cancer support canada.
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