CINCINNATI—Another cancer screening controversy has men looking for answers this time.
Just like breast cancer screening was thrown into confusion last year by new guidelines issued by a government task force, prostate cancer screening has a controversy of its own with new recommendations published by the American Cancer Society (ACS).
"You could take out the word mammogram and substitute PSA,” says Bruce Bracken, MD, a professor of surgery in the division of urology at the University of Cincinnati (UC) College of Medicine and a UC Health urologist, referring to the latest controversy.
On March 3, 2010, the ACS published new recommendations urging men to discuss the benefits and risks of prostate cancer screening with the prostate-specific antigen (PSA) blood test and digital rectal exam. The advice is based in large part on early findings from two studies—one American and one European—that cast doubts on the efficacy of screening for the slow-growing cancer.
In the American study, according to the ACS, researchers found little difference in prostate cancer death rates between groups that received annual screenings and groups that received "usual care” (no recommendation for or against screening) in men ages 55 and over. In the European study, researchers found that screening reduced the rate of prostate cancer death by 20 percent but also found that 48 men would need to be treated to prevent one death from prostate cancer.
Richard Albin, PhD, who discovered PSA in 1970, recently wrote a column in the New York Times headlined "The Great Prostate Mistake” in which he called for an end to "inappropriate” use of PSA screening, noting that the annual cost is at least $3 billion. He also pointed out that American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it.
Noting that prostate cancer treatment can have lifelong side effects of incontinence and sexual dysfunction, the ACS now recommends that doctors more heavily involve patients in the decision of whether to get screened for prostate cancer. Such a conversation should begin at age 50, the ACS says. Men at high risk—African-American men and men with a family member diagnosed with prostate cancer before age 65—should begin such conversations at age 45 or even earlier, at age 40, if multiple family members have been diagnosed.
"Screening of course costs money, causes a lot of treatment and causes a lot of anxiety,” Bracken says, "but the strongest proponents of cancer screening are the people whose cancers have been screen-detected.
"It’s one thing to ask if the life expectancy of American men will be longer if we do PSA screening,” he adds. "But it’s quite a different matter if the question becomes, ‘Will the life of Mr. Smith be longer?’”
A typical patient who undergoes the PSA blood test and has an abnormal result, Bracken says, would likely be asked to have the test repeated to rule out a laboratory mistake. If the result was still abnormal and the patient had a 10-year or more life expectancy, a biopsy would be recommended (Bracken agrees with the ACS that men with less than a 10-year life expectancy should not be offered screening because the risks outweigh the benefits). Based on the result of the biopsy (an office procedure that takes five to 10 minutes), treatment options would be discussed.
"I’m old enough to remember the days before prostate cancer screening when an otherwise healthy person would come in with a pain in his back and find out that he had widespread prostate cancer that he would ultimately die from,” says Bracken. "Because of prostate screening, we hardly ever see that anymore.”
As for the digital rectal exam, Bracken says that in addition to its role in prostate cancer screening it can also discover anal or rectal cancers and fistulas (abnormal openings between two organs) of the anus or rectum, which are commonly caused by inflammatory bowel disease.
Ultimately, Bracken says, the goal of prostate cancer treatment should be to eliminate invasive forms of surgery and lessen the impact of radiation therapy to the point where prostate cancer treatment is no more innocuous than removing a skin lesion.
"We’re not there yet,” he says. "In the meantime, we should continue to evolve and find treatments that don’t negatively affect the patient’s quality of life.”