David’s friend, Jerry, went through the prostate wars more than a decade ago. He discussed the PSA test with his doctor and made what seemed to him an easy decision. The consequences were not at all easy: high PSA numbers, anxiety, biopsies, more anxiety and, finally, radiation treatment for prostate cancer. He now has sexual problems as side effects of treatment but considers himself a cancer survivor and has high praise for the PSA test.
Despite Jerry’s experience–or maybe partly because of it–David was not so enthusiastic about screening. His friend, Jerry, was incredulous: “The PSA test saved my life, and it could save yours too!”
Then in May of 2012 the U.S. Preventive Services Task Force (USPSTF) recommended against PSA screening. After examining all the research, including two large recent studies, the Task Force concluded that screening for prostate cancer with the PSA blood test “has more harms than benefits.” David feels vindicated.
At first, the American Urological Association objected strongly, calling the advice “inappropriate and irresponsible.” The group later backed off from that position and has established new guidelines, recommending “a more selective approach in order to maximize benefits and minimize harms.”
What Can Take Its Place
Since that time, PSA testing has declined substantially, and the greatest decrease in use has been among urologists. The recommendation has changed clinical practice, but the question remains: how can an individual protect himself against prostate cancer?
Prostate cancer in its early stages rarely produces any symptoms that are easily recognized. Frequent urination, particularly at night; difficulty urinating; pain while urinating; or blood in the urine can be a sign of either prostate cancer or benign prostate enlargement–more often the latter. Symptoms such as bone pain usually occur only after the cancer has spread to other parts of the body and there is little chance of successful treatment.
Before the PSA test was introduced, digital rectal examination (DRE) was the major way of diagnosing cancer. But cancer is usually fairly far advanced when it is detected through DRE. And the U.S. Preventive Services Task Force also recommended against that test, for the same reasons as for PSA screening. Both tests have too many false positives that result in too many biopsies that are not always harmless. And treatment of localized prostate cancer is not always necessary but capable of causing severe side effects.
Both tests also produce numerous false negatives. About 15 percent of men with a “normal” PSA score may have cancer; 66 percent of those with “abnormal” scores don’t have cancer. It’s true, however, that men with high PSA scores are more likely to have cancer of the prostate, and the American Urology Association is convinced that lives have been saved as a result of early detection, even though solid proof of this is still lacking.
The idea that early treatment prevents serious complications is a sound one that holds true for most diseases and most cancers. For prostate cancer, the advantage of early detection and treatment is not so clear cut.
Some cancers grow so aggressively that they cause death even with early and frequent screening. On the other hand, most tumors grow so slowly that they will probably never cause harm.
Treatment for prostate cancer is far from benign. One percent of patients die; others suffer serious, lasting effects to sexual, urinary and/or bowel function. The USPSTF determined that one thousand men must be screened–with many undesirable consequences–in order to save one life.
In the aftermath of the Task Force’s recommendation, a man’s decision regarding PSA screening has become increasingly complicated.
If you’re under age 40, the American Urological Association recommends against screening since there is a very low prevalence of cancer at this age.
If you are between ages 40 and 54 and are of average risk, routine screening is likewise not recommended. If you have risk factors such as being African American or having a father or brother diagnosed with prostate cancer, you may want to discuss the matter with your doctor.
If you are age 70 or over or have a life expectancy less than 10 to 15 years, screening is not recommended because cancers generally grow slowly.
If you are 55 to 69 years of age, on the other hand, you are are in a high risk category and should carefully weigh the benefits and risks of screening. The AUA panel “strongly recommends shared decision making...and proceeding based on a man’s values and preferences.”
For men who choose screening, the AUA now recommends PSA testing once every other year rather than annually.
Because of potential physical and psychological consequences, the decision to have the test should never be taken lightly. Prostate is the most commonly diagnosed cancer in men, and some estimate that at least a third of all males age 50 and over will develop a cancer at some time in their lives. Yet the average lifetime risk of dying from the cancer is three percent, only slightly lower than it was three decades ago, before the PSA test was available.
In the past, most men undergoing biopsy and given a diagnosis of cancer opted for treatment–either with radiotherapy or surgical removal of the prostate. Even knowing the potential side effects, they wanted the cancer removed.
Today, the option of watchful waiting is more often recommended and chosen. This involves regular monitoring with PSA tests, digital rectal examinations, imaging and biopsies to make sure the cancer hasn’t progressed.
Some believe this approach is appropriate for about 40 percent of American men diagnosed with prostate cancer. For these men, the cancer occurs in only a small part of the prostate and has not spread outside the gland.
Another option is the one that David made even before the USPSTF recommendation. “I may well have a cancer in my prostate gland; many men my age do,” he said. “ But sexual and urinary function are important to me. I don’t want to lose them just for the assurance that I have eliminated a cancer that may or may not ever cause harm.”
REFERENCES:
N. Agarwal, et al, “New agents for prostate cancer,” Annals of Oncology, 2014;25(9):1700-1709.
American Cancer Society, “Testing for prostate cancer.”
American Cancer Society, “Considering prostate cancer treatment options,” last medical review, August 26, 2013.
American Urological Association, “Early detection of prostate cancer: AUA guideline.” 2013.
Gerald Chodak, M.D., “Should higher risk=earlier screening for prostate cancer?” Medscape Urology, September 23, 2014.
Peter Jaret, “Your prostate cancer treatment options,” WebMD Feature, reviewed by Brunilda Nazario, August 31, 2012.
Narelle Hanley, et al, “A qualitative insight into psychosexual adjustment to prostate cancer,” BMC Urology, 2014;14(56)
Katie Johnson, “Adding ADT to RT also best in milder prostate cancer?” Medscape, April 14, 2014.
Karen Kaplan, “Urologists say most men may skip PSA test for prostate cancer,” Los Angeles Times, May 3, 2013.
Fran Lowry, PSA screening for prostate cancer declines in US,” Medscape Medical News, March 21, 2014 (Journal of Urology, December 14, 2013).
Fran Lowry, “Revamped prostate cancer risk calculator now online,” Medscape Medical News, August 8, 2014 (JAMA, August 4, 2014).
Mayo Clinic Staff, “Prostate cancer,” MayoClinic.com, May 7, 2013.
NickMulcahy, “High-dose RT is a ‘conundrum’ in localized prostate cancer,” Medscape Medical News, September 24, 2014 (American Society for Radiation Oncology (ASTRO) 56th Annual Meeting, September 15, 2014.
National Health Service (UK), “Should I have a PSA test?” NHS Choices, last reviewed January 15, 2013.
Urology Care Foundation, “Localized prostate cancer.”
Roxanne Nelson, “Six months of ADT plus radiotherapy halves prostate cancer mortality,” Medscape, March 25, 2011.
Roxanne Nelson, “PSA screening does reduce deaths, but is not recommended,” Medscape Medical News, August 6, 2014 (Lancet, August 7, 2014).
Roxanne Nelson, “Surgery trumps surveillance in major prostate cancer trial,” Medscape March 6, 2014.
Roxanne Nelson, “Vasectomy linked to higher risk for lethal prostate cancer,” Medscape, July 11, 2014.
Roxanne Nelson, “Male pattern baldness linked to aggressive prostate cancer,” Medscape, September 15, 2014.
Prostate Cancer Foundation, “Treatment options.”
Prostate Cancer Treatment PDQ, Patient version, last modified September 12, 2014.
“Treatment options for prostate cancer,” Cancer Research UK.
12/19/2014
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