Get Screened
Prostate Cancer Can Be Detected Early
Recent research published in the New England Journal of Medicine (March 26, 2009) questioned the validity of PSA testing in reducing the overall death rate from prostate cancer. Two studies — one in North America, the other in Europe — illustrated both sides of the long-standing controversy. One study from North America showed no reduction in prostate cancer deaths in those screened while the European study found a 20 percent reduction in mortality.
In reviewing these two studies, St. Louis urologist Salim Hawatmeh, MD, says that the latest research enhances awareness of prostate cancer in general, which is a good thing. Dr. Hawatmeh believes strongly that the value of regular screenings, including the use of an annual PSA test coupled with a digital rectal exam, is beneficial.
Says Dr. Hawatmeh:
I commend these recent studies for bringing awareness to prostate cancer in general and PSA screening. Despite the conclusions drawn from these reports, however, there is an overwhelming body of evidence that supports the value of screening for prostate cancer with PSA and DRE. There is no question these screening tests save lives. We've seen a reduction in the mortality from prostate cancer over the past 20 years during the period of time that PSA has been used. The benefits of screening far outweigh the risks of forgoing the test, especially for men at risk because of family history or those between the ages of 50 and 75. Men age 75 and above can choose to be screened less frequently. As men age, the prevalence of prostate cancer increases, but the tumors tend not to be lethal in the oldest age groups.
Symptoms of Prostate Cancer
Prostate cancer, certain bladder conditions or a benign enlargement of the prostate gland may have these symptoms:
Frequent or urgent need to urinate
Slow stream or straining to urinate
Waking up at night to urinate
Blood in urine or semen
Detecting certain types of prostate cancer early can be critical. Elevated PSA results may reveal prostate cancer that's likely to spread to other parts of your body (metastasize), or they may reveal a quick-growing cancer that's likely to cause other problems. Early treatment can help detect cancer before it becomes life-threatening or causes serious symptoms. In some cases, identifying cancer early means you will need less aggressive treatment, reducing your risk of side effects such as erectile dysfunction and incontinence. If you are in a group of men at high risk of prostate cancer, you're even more likely to benefit from PSA tests. Older men may choose not to treat their prostate cancer and instead be placed on a program of watchful waiting or active surveillance. Not all prostate cancers are the same, however; there are less aggressive and more aggressive types. With a diagnosis of prostate cancer, older men can discuss the risks and benefits of possible treatments with their Urologists, and make an informed decision based on his individual case. One cannot lump all prostate cancer patients in a single group, young or old. What is the right option for one patient may not be recommended for another.
Prostate cancer treatment is based on the overall health of the individual. There are men in their low 70's, for example, that are in better shape and have less medical issues than some men in their 50's. Clearly these types of patients have many more years ahead of them. As physicians, we certainly should not deny these men screening for prostate cancer and state-of-the-art treatment options based solely on age. We need to discuss the risks and benefits of all options which can prolong their lives while maintaining quality of life.
Despite the media buzz these two recent studies created, no definitive conclusions can be drawn from them. I will limit my comments to the U.S. study, which involved 10 centers across the U.S. They enrolled about 76,000 men from 1993 to 2001. There are three main issues with the U.S. study. First, the cutoff point for doing a biopsy was 4 ng/ml. If a study were to be set up today, that would not be the criteria for doing a biopsy. An age-adjusted PSA scale would be used. Second is the issue of contamination. 52% of the men in the non-screened arm had a PSA documented within the past few years of the study, as opposed to 85% in the screened arm. In other words, a significant portion of men in the non-screened arm were, in effect, screened. Given this fact, it is not surprising that there was only a modest increase in the number of cancers diagnosed in the screened arm, only 20%. The most problematic part of this study, however, is the relatively short follow-up period - average follow-up of 11 years. The mortality for prostate cancer within the first 10 years is small, but with the numbers generated from this study of about 50 and 44 in each arm, it is difficult to make a statement about differences in outcome given this significant limitation.
There is no doubt these studies have raised the national debate on PSA screening. Once we as Urologists are able to tell the indolent prostate cancer that does not need to be treated from the aggressive cancer that does, the PSA screening controversy will diminish. After all, it is the treatment for prostate cancer that may expose men to side effects that may compromise their quality of life, and quality of life of their partners. I hope that one day this better understanding of prostate cancer reduces the potential harm to men.
It is important to note that the current recommendations from the American Cancer Society and the American Urological Association support screening for prostate cancer with PSA and DRE beginning at age 50. Screening should begin at age 40 in individuals with a family history of prostate cancer and African-Americans, two groups at higher risk of developing the disease.
I encourage patients to become fully informed, to consider their preferences and values about all their medical decision, including PSA screening. We as physicians can help patients know there are trade-offs, that there are potential benefits and there are potential harms.
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