Prostate Cancer Screening

This week a gentleman I’ve known for a number of years came to the office with lab results to discuss.  He had had bloodwork done as part of routine screening by his employer, including a PSA (prostate specific antigen) test.  He felt well and had no symptoms to suggest a problem with his prostate but the PSA was done and it came back abnormal.

Recently there has been a lot of controversy about prostate cancer screening.  My patient and I had the opportunity to discuss the current recommendations and decide on a plan to address that abnormal result, but I also wanted to share the current recommendations and the reasoning behind them with all of you.  (Last week’s blog post was for the ladies, and this one’s for the gentlemen in the audience, LOL.)

So what’s the prostate gland?  It is a gland about the size of a walnut that sits underneath the bladder.  It provides fluids to protect and nourish sperm after ejaculation.

The prostate gland is very sensitive to testosterone and tends to gradually get larger as a man ages.  Unlike women, men don’t really go through a “menopause” phase of life when their gonads stop making sex hormones.  Testosterone production may decrease as a man gets older but it doesn’t stop altogether.

Cancer of the prostate gland is the most common cancer in men.  In the US about 233,000 men are diagnosed every year with prostate cancer and over his lifetime a man has a 16% chance of developing prostate cancer.  Given how common it is, a lot of effort has been devoted to finding a good screening test.

There are two main problems with screening for prostate cancer.  Prostate cancer is certainly common enough to be a good candidate for screening, but we just do not have a good screening test.  An abnormal PSA blood test (over 4.0 is the most commonly used upper-limit-of-normal), has a 70% false-positive rate, and the only way to determine whether a level over 4.0 actually represents a cancer is to do a biopsy.  Biopsies miss 10% of prostate cancers and are associated with anxiety, pain, fever and blood in the urine and semen.

Worse, as many as 15% of men who have a PSA less than 4.0 will have prostate cancer if you do a biopsy.  Adding a digital rectal exam to the PSA blood test really doesn’t add any additional benefit.

The bigger problem with screening for prostate cancer, though, is that finding and treating it early does NOT save lives.  I know that’s hard to believe, especially with all the press about breast cancer screening.  Unlike breast cancer which tends to be aggressive, prostate cancer tends NOT to be aggressive.  50% of prostate cancers found on screening will not cause symptoms in the patient’s lifetime.  The 15-year mortality rate for low-grade prostate cancers is less than 5%.

How many of you men out there would be comfortable with a watch-and-wait approach if you were told you had prostate cancer?  I know, not many of you.  90% of American men diagnosed with prostate cancer choose to be treated.  However, treating prostate cancer can involve surgery, chemotherapy, radiation, or a combination of all three.  These treatments have risks in and of themselves.

Removing the prostate gland often damages the nerves of the pelvis and can cause urinary incontinence and loss of erectile function.  Chemotherapy obviously weakens the immune system, leading to infections, and can cause other side effects like permanent nerve pain.  Radiation to the pelvis can cause urinary incontinence, stool incontinence, diarrhea and pain.

Current recommendations are NOT to screen men routinely for prostate cancer.  If a man has symptoms related to his prostate, then by all means we will check it out, but at that point the test is NOT for screening, it is a diagnostic test.  We definitely should not be screening men at low risk for prostate cancer before age 50 or after age 70, or if a man’s life expectancy is less than 10 years.

Men at higher risk of prostate cancer should have a thorough discussion with their doctor about the risks and benefits of screening.  These include black men and men with a family history (father or brother) of prostate cancer diagnosed before age 65.

At this point prostate cancer screening is an example of the medical field overtesting and overtreating.  We find cancers that won’t cause problems for the patients, take a healthy man and give him a scary diagnosis that steals his peace of mind.  Then we subject him to treatments that CAUSE illness without PREVENTING illness.

More research is needed to discover better tests to screen for prostate cancer.  Until that time, and until we have less toxic treatments, routine screening is not recommended.

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  1. Pingback: Preventive Care | Southwest Sentry

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