Doctors differ on prostate screening

Prostate screening tests detect prostate cancer early, but questions about whether the tests do more harm than good have made them one of the most hotly debated areas of medicine.

9 jun 2013--Some doctors and researchers believe testing for PSA, which stands for prostate-specific antigen, leads to unnecessary, costly and even harmful medical procedures because so many early diagnoses are slow-growing cancers that don't require immediate treatment. But men typically demand care once they hear the "C" word.

Those on the other side say PSA screening remains a valuable tool for detecting cancer early and saving lives.

Last month, The American Urological Association reversed course and no longer recommends routine screening for men 40 to 54 years old, who face an average risk of getting prostate cancer. It said testing should be considered primarily for those 55 to 69. Even then, a PSA testshould not be automatic. Men should talk to their doctors about the benefits and risks and "proceed based on their personal values and preferences," the association recommended.

The urology group's announcement followed the 2011 recommendation by the United States Preventive Services Task Force, arguing against routine screening in healthy men because it often leads to unnecessary biopsies and surgery as well as life-altering complications such as impotence and incontinence.

A problem with screening is that PSA levels can be high, indicating cancer, even when a man doesn't have it. Another issue is that if a biopsy detects cancer, it is often very slow-growing and, as cancers go, relatively benign.

In other words, a PSA test was taking healthy men and turning them into cancer patients who underwent radiation therapy, surgery and other invasive procedures for something that would never cause death or even lead to any symptoms.

But even seemingly benign cancer can turn serious. And some men want to turn back any risk of cancer immediately.

Four years ago, Michael LeBlanc, 62, didn't even think about waiting to treat cancer detected in his prostate. Whether the cancer was slow-growing or more aggressive was a moot point, he said.

"Although it's slow growing, what says tomorrow it won't change?" said LeBlanc. "It's like calling 911 and you say there is a man who broke into the house but he looks like such a nice guy, I don't think he's going to hurt us right away. A home invasion in a home invasion. Cancer is cancer. You don't dilly dally with that." LeBlanc of Canton underwent robotic surgery to remove his prostate. He said an analysis indicated the cancer "had consumed my prostate." Exercise, he said, helped him make a full recovery.

Dr. Otis Brawley, chief medical officer for The American Cancer Society, has long called for more caution with prostate cancer screening, speaking against mass screenings such as the ones offered by health companies at shopping malls.

Many patients, he said, don't fully realize the potential complications associated with PSA testing.

"My whole campaign has not been one that men should not be screened," he said. "Let the man know the pluses and minuses, and what we know about the disease and the screening of the disease and then let the man decide," Brawley said.

That decision, he said, should be based on weighing the benefits versus potential harm of screening. Research of men 55 to 69 suggests PSA screening may prevent one death from prostate cancer for every 1,000 men screened at two-to-four year intervals over a 10-year-period, according to The American Urological Association. At the same time, many men who get the screening will be harmed because of treatments that can lead to health complications. Even a biopsy poses a risk of infection, for example.

Doctors may recommend "active surveillance" for men with low-risk prostate cancer tumors, in which the tumor is regularly monitored rather than treated. But getting patients to watch and wait is a difficult.

"Part of it is a reaction to cancer. The 1970s Nixon War on Cancer and there's this concept that all cancer is bad," said Dr. Martin Sanda, chairman of the Department of Urology at Emory University School of Medicine and director of the Prostate Cancer Center in Emory's Winship Cancer Institute. "But now we are pushing the envelope. Many of these (cancers) can be watched." Over a 5-to-10-year period, about a third of men whose cancers are considered low risk turn worse and require treatment, according to Sanda.

Sanda said a patient's decision about whether to monitor the low-risk cancer or undergo treatment often depends on how the information is presented. The key, he said, is explaining that the biopsies not only detect aggressive cancers that need immediate treatment but also pick up cancers that are "quasi cancer" and safe to watch rather than treat immediately.

But not all doctors are entirely comfortable with the concept of simply waiting and watching.

"These so-called quasi cancers may not be a problem at all. And there's also the possibility these quasi cancers can spread," said Dr. Marc Harrigan, a primary care physician at Piedmont Hospital. "You've got to put yourself in the shoes of the patient: 'Do I want something inside of me?' I mean, how comfortable would I be as a patient knowing there is a cancer inside of me that can grow at any time?" Harrigan said his patients are predominantly African-Americans who face a higher risk for prostate cancer. They tend to opt for screening before 50. But Harrigan reviews the pros and cons of testing for any patient 40 and up. And then he lets the patient decide whether or not to get the PSA test.

"Who am I to tell patients you really shouldn't be tested until 50?" said Harrigan.

Sanda remains an advocate of screening - which includes not only the PSA blood test but also the digital rectal exam. He sees firsthand what can happen when prostate cancer is not caught in the early stages.

"I see patients every month who are in their late 40s and early 50s and their cancer is too far along and we can't do anything to treat them," he said.

Sanda is also studying a new, more sophisticated blood test that could change the way men are screened. Studies indicate The Prostate Health Index or phi, is more precise than the PSA and better distinguishes an aggressive cancer from a low-risk cancer. It's one of several tests being studied across the country with the same goal: to have more accurate information, prevent unnecessary biopsies and treatments and the anxiety that often accompanies them, while saving lives from a disease expected to kill almost 30,000 men this year alone.

—-

Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society's estimates for prostate cancer in the United States for 2013 are:

-About 238,590 new cases of prostate cancer will be diagnosed

-About 29,720 men will die of prostate cancer

-Prostate cancer can be a serious disease, but most men diagnosed with prostate cancer do not die from it. In fact, more than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today.

-About 1 man in 6 will be diagnosed with prostate cancer during his lifetime.

-Prostate cancer occurs mainly in older men. Nearly two thirds are diagnosed in men age 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 67.

©2013 The Atlanta Journal-Constitution (Atlanta, Ga.) 

Guidelines for prostate screening widely ignored

A surgical team performs a robotic prostatectomey at the University of Chicago Medicine Credit: Bruce Powell for the University of Chicago Medicine

New research confirms that the controversial decision by Warren Buffet – the 81-year-old CEO of Berkshire Hathaway – to undergo a blood test screening for prostate cancer despite his age is hardly unusual. Despite recommendations in 2008 from the United States Preventive Services Task Force against testing for prostate cancer in men aged 75 years or older, almost half of men in that age group continue to get screening tests.

28 april 2012--In 2005, before the recommendations were released, 43 percent of men age 75 and above elected to take the prostate-specific antigen (PSA) test. In August 2008, the Task Force stated it "recommends against the service," arguing "there is moderate or high certainty the service has no net benefit or that the harms outweigh the benefits."
Survey results from 2010, however, published in the April 25, 2012, issue of JAMA, found that two years after the Task Force's recommendations were announced, the screening rate for that group of men had gone up slightly, to 43.9 percent. This is higher than the rates for men in their 40s (12.5 percent) or 50s (33.2 percent), who are more likely to benefit from early diagnosis and treatment. Only men aged 60 to 74 were more likely to get the screening test (51.2 percent).
"PSA screening for more than 40 percent of men 75 or older is inappropriate," said study author Scott Eggener, MD, assistant professor of surgery at the University of Chicago Medicine. "Selective screening is reasonable to consider for the healthiest men over age 75, but for the large majority of men in this age group, early detection can lead to treatment of a disease that will probably never cause a problem. A substantial proportion of men over 75 with an elevated PSA will die from something else before a prostate cancer interferes with the quality or duration of their life."
"Our data are likely an underestimate," the authors note. They worked with information from the 2005 and 2010 Cancer Control Supplements, part of the annual National Health Interview Survey (NHIS), which gathers information through in-person interviews and is a representative sample of the US population. "Self-reported screening rates in the NHIS," they note, "are predominantly lower compared with medical record extraction."
The revised draft recommendations presented in October 2011 by the USPSTF are even more critical of PSA screening than the 2008 version, suggesting there was not enough evidence that PSA screening improves health outcomes to routinely recommend the test for men at any age. "Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality," the Task Force concludes. It is associated with "harms related to subsequent evaluation and treatments, some of which may be unnecessary." These draft recommendations are not finalized yet but are expected to be forthcoming soon.
Clinical practice patterns following the 2011 USPSTF recommendations "should be monitored," the study authors conclude. Even if PSA screening is discouraged in the final USPSTF recommendation, "I'm not anticipating a massive change in utilization," Eggener said, based on a general tendency for individuals and physicians to support cancer screening, evidence that fewer men are dying of prostate cancer since the introduction of PSA, subsequent confusion about the recommendation among the general public, and ongoing concern about the disease.
Provided by University of Chicago Medical Center

Does prostate screening make sense for you?

By Dr. Steven Woloshin and Dr. Lisa M. Schwartz

05 oct 2008--For years, American men have gotten a clear message: worry about prostate cancer, and get tested. The media, celebrity and politician testimonials, national prostate cancer awareness week - even a US Postal Service stamp - provide constant reminders that men face a big risk and that prostate-specific antigen screening is the responsible thing to do.
The commonly cited statistics are stark: almost 220,000 American men were diagnosed with prostate cancer last year; it is the most common nonskin cancer and the second-biggest cancer killer among men in the United States.
The message has gotten through. Most American men over 50 undergo prostate cancer screening: in 2006, nearly two-thirds of men between 50 and 74, and three-quarters of men older than 75, were screened in the past two years. Specialists have estimated that more than 1 million men have been diagnosed with prostate cancer because of screening.
But now the United States Preventive Services Task Force, the preeminent body making recommendations on preventive medical services in this country, has told physicians not to screen men 75 and older, and said screening for younger men is a toss-up.
The reason: Prostate cancer screening is a tradeoff between an uncertain benefit and known harms.
We don't know whether PSA screening (a blood test for prostate cancer) saves lives since the gold standard, randomized trials, have not been completed. But we do know that screening causes harm, such as false alarms leading to unnecessary biopsies and, more importantly, unnecessary diagnoses: finding cancers that would never have caused symptoms or death if left undetected.
PSA screening results in a lot of unnecessary diagnoses. But since there is no way to know whether an individual man has been unnecessarily diagnosed, most men with screen-detected prostate cancer get treated. That means there is a lot of unnecessary treatment (the cancers destined to never cause harm cannot be helped by - and do not need - treatment). Unfortunately, unnecessary treatment can cause harm, leaving a substantial proportion of men impotent or incontinent.
The task force concluded that for older men, harms outweigh benefits. They concluded that, for younger men, the balance of benefits and harms is too uncertain to justify recommending for or against screening. These men need to decide for themselves.
Shifting messages and limited evidence may leave men frustrated and confused. How can they decide what to do in the face of so much uncertainty?
The first step is to ask how big their risk of prostate cancer really is. If a man feels the risk is high, he might be willing to take the chance that screening does more good than harm; if he feels his risk is low, he may opt to forgo screening.
How can he judge this risk? Intuition tells him the risk must be big, given the commonly reported statistic: "220,000 cases diagnosed last year." But this statistic is deceptive because screening itself inflates the number of cases because of unnecessary diagnosis.
The result, ironically, is a self-reinforcing cycle: an inflated sense of risk leads more men to get screened; as more cases are detected, the risk looks bigger.
A better gauge of the true threat from prostate cancer is the chance of dying from it. But the most familiar statistic - 28,000 prostate cancer deaths last year - hides critical detail: the risk of prostate cancer death changes dramatically with age. That number also lacks perspective: other causes of death rise even faster with age. Without age-specific statistics and perspective, many men are probably left with an exaggerated sense of risk.
Our research shows that for younger men, there isn't much prostate risk to reduce. For the average 50-year-old, the chance of dying of prostate cancer in the next 10 years is 1 out of 1,000. Another way to say this is that, over the next 10 years, 999 out of 1,000 will not die from prostate cancer. For perspective, the risk of dying in an accident over this time is five times greater.
Risk increases with age, but does not reach 10 out of 1,000 until age 70. Some may feel that this amount of risk is insufficient to justify the potential harms of screening; others may feel that the risk is big enough. Men need to decide for themselves.
The risk to older men is indeed greater; by age 75, the 10-year risk of prostate cancer death approaches 20 in 1,000. But again, this number should be put in perspective. For men who never smoked, the chance of heart attack death is seven times greater than the chance of prostate cancer death. For current smokers, the chance of dying from either a heart attack, lung disease, or lung cancer is 20 times greater than that of prostate cancer.
Our point is not to minimize the real suffering caused by prostate cancer. It can be a terrible, fatal disease. Rather, it is that prostate screening has been heavily marketed to the public for years in ways that have exaggerated the risk of cancer and the benefit and safety of screening.
To really help men, we need to help them understand the risks they face and which ones can be reduced with interventions of proven benefit.
The authors are general internists at the Department of Veterans Affairs Medical Center in White River Junction, Vt., associate professors at the Dartmouth Institute for Health Policy & Clinical Practice in Hanover, N.H. , and the authors of Know Your Chances; Understanding Health Statistics.