With just a few minutes of research on prostate cancer, you will find that it is the most common cancer in men; approximately 1 in 6 men will develop prostate cancer in their lifetime. In these few minutes you will also identify the only two methods available for prostate cancer screening: PSA tests and digital rectal exams (DRE). Alone, these exams are not very sensitive in detecting prostate cancer, but together, they can allow doctors to identify those men at greater risk for prostate cancer. A majority of patients are diagnosed by PSA and there is a growing concern that the disease is being over diagnosed and over treated. While this may be true, 30,000 men die annually from prostate cancer, so we cannot discount this method of screening entirely.
The PSA test was introduced in 1986 and, since then, we are diagnosing cancer earlier, when it is in a more treatable stage. With that said, however, PSA is not a perfect test. Prostate cancer is often considered a slow-progressing cancer, taking many years, even decades, before it manifests itself, yet it can also behave in a highly aggressive manner. A PSA test is not able to differentiate between these two cases. Often, we don’t know how serious the cancer is until it is removed. Currently, PSA screening is being used incorrectly, but this does not mean we should discount it altogether. Recent statistics show that only 24% of men in their 50’s get screened, the same percentage as men in their 80’s. This has occurred despite the Task Force’s recommendation against screening men over age 75. This is also true among the sickest Americans: over 30% of men who are not likely to live more than 5 years are being screened.
The U.S. Preventive Services Task Force specifically recommends against prostate cancer screening in men aged 75 and older and cites inconclusive evidence to assess the pros and cons of prostate cancer screening in men aged less than 75. It is important to remember that these recommendations only apply to healthy men without symptoms; this does not apply to men who already have symptoms or already underwent treatment. Another large randomized controlled trial not mentioned by the Task Force showed that prostate cancer mortality was reduced by half over a 14-year study period. This paper is more influential because it had a longer follow-up than the other two. A longer follow-up allows for the effects of PSA screening on prostate cancer specific mortality to become apparent. Additionally, this study included younger subjects who are more likely to benefit from early screening. This study also reported that patients diagnosed by PSA had lower incidence of advanced disease compared to their non-screened counter-parts. I believe that it is important to take all published literature into account before making such drastic recommendations.
To make a long story short, PSA screening does save lives. It also results in some unnecessary harm, although it’s impossible to say in which people until after they’ve already been treated. So discuss with your doctor what you would like your treatment regimen to include – make your treatment decision together. Tell them what is important to you. And, as always, do your diligence and research your treatment and physician options carefully. A high PSA reading does not lead you down a treatment-only path, just as prostate cancer treatment does not lead you down the road to sexual or urinary dysfunction; one can exist without the other.
David B. Samadi is Vice Chairman, Department of Urology, Chief of Robotics and Minimally Invasive Surgery, The Mount Sinai Medical Center.
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