Guidelines for Patients Regarding Prostate Cancer Screening

Why screen for prostate cancer? Screening finds early cancers, allows for simpler treatments with less side effects and, in long term studies, has saved lives. For example, in 1985, prior to PSA screening, the prostate cancer 5 yr survival rate was 69% compared to 99% in 2006. Whether this is completely due to screening or better treatment is not known, but probably due to both.

Why is there a controversy about screening for Prostate cancer?

Prostate cancer can be very slow growing and therefore demonstrating a survival benefit, early on, is difficult. If a man has a short life expectancy the cancer may never affect him. In addition the side effects of a biopsy can be uncomfortable and treatment effects may be difficult to live with. Two large studies were conflicting in whether screening decreases deaths. Both looked at 10 year survivals between screened and non screened patients and didn’t show a difference. However the longest randomized study (Goeteborg) did show that there was improved survival if you looked at the period from beyond 10 years.Bottom line is that if you plan to live more than 10 years ,screening for prostate cancer may be beneficial.

The screening studies to date have all focused only on survival and side effects of radical prostatectomy. The side effects of patients who had Brachytherapy or external radiation ( which have lower side effects in most areas) were not included . Also there has been no study on how a persistent cancer without treatment affects a man’s life. Bottom line : Screening studies reported by the popular press have not looked at the whole picture. Screening can be beneficial . While treatment may not be necessary in all men as a man may have a short lifespan and the cancer may not advance, it is often impossible with reliable accuracy to determine either the lifespan of a patient nor the aggressiveness of the cancer,. For example ,one of our physician’s father had a 5 vessel coronary bypass the year before he was diagnosed with PCa. He was not expected to live for more than a few years because of his heart disease. He went ahead and had a seed implant, his cancer never recurred and he lived another 22 years!

If we find PCa early should we treat it? Many have argued, including some of the large patient support groups, that even if we screen for and find early cancer, that 20-30% of these men don’t need to be treated because they would have died of something else before the cancer affected them. This is true . However, even with early disease ,a no treatment (active surveillance) approach should be done with caution, as there is no reliable way to predict at the time of diagnosis if a low risk patient truly has low risk disease or will soon  progress to advanced disease. We have found with some of the new imaging technology, undetected aggressive cancer at the time of diagnosis elsewhere in the gland.  A biopsy is only a sample. Therefore a no treatment approach should be accompanied by an aggressive surveillance plan and we believe a n imaging workup, to confirm this approach is reasonable.

Routine Screening and Intelligent Screening

The US Preventative Task Force recently suggested, on the basis on only 2 studies considered to be fair ,and 2 studies considered to be poor, that routine screening should not be recommended to patients. However there was no prostate cancer experts on the task force. When the task force reported their recommendation, there was almost universal condemnation by experts in prostate cancer. The task force refused to change their opinion. In fact, according to one other members of the panel, the task force has never changed their opinion of any recommendation after outside expert advice. However one aspect came out of the Task force that brought up an important question.  Does every man need routine screening i.e every year after 50? Routine yearly screening after 50 made it easy for everyone to remember but it probably isn’t  necessary for everyone. We believe that  a more sensible approach is to do intelligent screening in order to prevent unnecessary deaths and morbidity from PCa. It takes more work but it can decrease the overall cost and effectively accomplish the goal of finding cancer early.

Intelligent Prostate Cancer Screening

What tests? A PSA blood test is minimum. A digital rectal exam is also recommended

Who should be screened and when? Many of the professional organizations have screening recommendations and they do not all agree. It is confusing even to the doctors who advise you. You should start to think about screening between 40 and 50 years old. Prostate cancer is rare prior to this time. Most men, with the exception of those described below, can begin after age 50. We believe it is reasonable ,however, in all men to get a baseline PSA between 40 and 50 and then make a judgment with their doctor from that reading on frequency thereafter. PCa is typically a slow growing cancer, therefore most of the organizations recommend screening only in healthy men with a life expectancy greater than 5 years.

Testing related to personal factors (our recommendations)

Age 40–45 Begin PSA testing if you have a male relative who had PCa and especially if they had it before the age of 60.

45-50 if you have a father brother uncle with PCa anytime or you are an African American

50 Reasonable time to get your first PSA if you have not already had one. Most PCa is in men over 65

50-75 yearly However if PSA 1-2ng/ml then every 2 years is ok

Over 75 Health factors weigh heavily If in good health reasonable to screen

Factors that may affect frequency of testing

PSA If the PSA is higher than 2.5 ng/ml or demonstrates a rapid rise ( eg from 1-2 in one year) then repeat every year and you should discuss this with your doctor and consider a biopsy.

Family History Family history increase your risk especially if you brother father, uncle, grandfather had PCa before 60 y/o. Consider yearly after 50

Ethnic Group African Americans are more likely to develop PCa . Consider yearly after 50

PSA   >4.0ng/ml? Talk to your doctor or urologist. A biopsy may be considered

Screening Facts 

• Screening with the PSA blood test detects cancer at an earlier stage than if no screening is performed.
• Prostate cancer screening is associated with a reduction in the risk of dying from prostate cancer if one considers the long run , > 10 years
• For men whose prostate cancer is detected by screening, it is not currently possible to  accurately predict which men are likely to or not benefit from treatment.
• Treatment for prostate cancer can lead to urinary, bowel, sexual, and other health problems that can be significant or minimal, permanent or temporary.
• The PSA and DRE can produce cannot predict accurately whether one has prostate cancer or not . Only a biopsy can determine this. They are only road signs.
• Abnormal results from screening with PSA and DRE may require prostate biopsies, which can be painful and lead to a small chance of complications like infection or bleeding.
• Not all men whose prostate cancer is detected through screening require immediate treatment. Some require periodic blood tests and prostate biopsies to determine the need for future treatment.

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