Posts Tagged ‘intermediate-risk’

Screening For Prostate Cancer Revisited

December 14, 2013

Blog # 132

The ignoramuses at the United States Preventive Services Task Force (USPSTF) gave Prostate Specific Antigen (PSA) testing a grade “D” recommendation and called for the complete abandonment of the test for prostate cancer screening.

Having lived and worked deep within the trenches of urology for over 25 years, I almost stroked when I read their recommendation. I previously crafted video responses:

and gave a “horse’s ass” award to the USPSTF in another video:

The Prostate Cancer World Congress took place in Melbourne Australia in August of 2013, where experts proposed a consensus view on the early detection of prostate cancer.  This material was published in the British Journal of Urology International.

The consensus was engendered by the great confusion generated after the USPSTF called for the total abandonment of PSA testing. The international experts who wrote the consensus statement included 14 international experts on prostate cancer, unlike the USPSTF, where there was not a single urologist on the committee.

The experts at the Prostate Cancer World Congress adopted the following five statements:   

  1. For men age 50–69, evidence demonstrates that PSA testing reduces death from prostate cancer by 21% and the incidence of metastatic prostate cancer by 30%.
  2. Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.  In other words, not everyone with prostate cancer will need to be actively treated and the potential side effects of active treatment should not influence the diagnosis of prostate cancer by the proper means.
  3. PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.  The experts proposed the use of prostate examination, family history, ethnic background, prostate volume, as well as a variety of risk models based upon PSA.
  4. Baseline PSA testing for men in their 40s is useful for predicting the future of prostate cancer. Men with baseline values that are high need further PSA testing.
  5. Older men in good health with over a 10-year life expectancy should not be denied PSA testing on the basis of their age.   This population of older men may certainly benefit from the early diagnosis of aggressive prostate cancers. This does not pertain to men with numerous other significant medical problems, but a healthy man in his mid-70s should not be denied PSA testing that might identify a cancer that has the potential to destroy his quantity and quality of life.  (In particular, the older man who comes to the office accompanied by his father should certainly not be denied!)

The consensus was that we should maintain the gains that have been made over the years since PSA was introduced—in terms of decreasing the number of men diagnosed with prostate cancer metastases (cancer that has spread) and reducing prostate cancer deaths—while minimizing the potential harms of over-diagnosis and overtreatment by increasing the use of active surveillance protocols in those men with low-risk prostate cancer.   Abandoning PSA testing as recommended by the USPSTF would lead to a reversal of all gains made over the course of the past 30 years.  Well-informed men should be offered the opportunity for early diagnosis of prostate cancer. To quote Dr. Jay Smith:  “Treatment or non-treatment decisions can be made once the cancer is found, but not knowing about it in the first place surely burns bridges.”

My take on the subject of screening for prostate cancer:

I like to keep things simple…I believe in two rules that are appropriate for medicine as well as just about everything in life.

Rule # 1: Do no harm.

Rule # 2: Do good.

To apply these rules to the game of golf, for example, “do no harm” means staying out of trouble as much as possible, keeping the ball out of the woods, bunkers and water hazards.  “Do good” by hitting the ball accurately in terms of distance and direction and setting up the next shot.

Screening for prostate cancer involves taking a medical history, doing a rectal exam to check the contour and consistency of the prostate, and a simple PSA blood test. “Do no harm” is satisfied because these tests are in no way harmful to the patient and provide information that is helpful, particularly when done on a serial basis, noting changes over time.

If exam shows an irregularity of the prostate, if the PSA is elevated, or if the PSA has accelerated significantly over the course of one year in a reasonably healthy man who has at least a ten-year life expectancy, doing a prostate ultrasound and biopsy is indicated. This test does entail a small risk of bleeding and infection, but the potential benefits far outweigh the risks.  “Doing good” is satisfied by the knowledge provided by the biopsy—the reassurance that comes from a biopsy report that shows no cancer and the potential for cure if the biopsy shows cancer.  Furthermore, the specific biopsy results along with other factors can predict which cancers are low-risk, which are medium-risk, and which are high-risk, important considerations in terms of active treatment versus active surveillance.

Many men who are found to have low-risk prostate cancer (low PSA; minimum number of biopsies showing cancer; low-grade cancer as determined by the pathologist) can be followed without active treatment (active surveillance) and those at greater risk can be managed appropriately (surgery or radiation), and many cured, avoiding the potential for progression of cancer and painful metastases and death—all while weighing the benefits of intervention against the risks.  Death from prostate cancer is unpleasant to say the least, often involving painful metastases to the spine and pelvis and not uncommonly, kidney and bladder obstruction, and our charge as urologists is to try to not let this scenario ever come to fruition.

One of our fundamental goals as urologists is to screen for prostate cancer—

the most common cancer in men present in 17% of the population—and if present, to provide appropriate guidance to best maintain both quality and quantity of life.  Anyone who reads the obituaries knows that prostate cancer is a cancer that is lethal, and if you don’t read the obituaries, I can promise you that prostate cancer kills in unkind ways. Even though only 3% of the male population dies from prostate cancer, that amounts to many thousands of men annually… and you do not want to be one of them.  I have my own PSA and prostate exam done every year and PSA screening was responsible for making an early diagnosis of my father’s prostate cancer in 1997, which was cured by surgery, resulting in a healthy and thriving, cancer-free 82 year-old man who will never die from prostate cancer.

BOTTOM LINE: PSA remains an invaluable screening tool for the detection of prostate cancer and ALL men ages 50 and over (40 if there is a family history) should be tested…IT JUST MAY SAVE YOUR LIFE!

Andrew Siegel, M.D.

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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

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Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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