Should You Be Screened for Prostate Cancer?
Bernie Wooden’s story is hardly unique. The prostate-specific antigen (PSA) test used to be given to men fairy routinely. And men around the country—and the world—believe they’re alive today because their doctors noticed a sudden increase in their PSA levels. But in 2012, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation against doing PSA screening for prostate cancer, saying that the harms of the test outweigh the benefits. That recommendation ignited a huge—and not always civil—debate among people who work in men’s health.
Some supported the USPSTF recommendation, saying that prostate cancer typically grows very slowly and men are more likely to die with prostate cancer then from it. These people also pointed out that the PSA test leads to overdiagnosis, and that an abnormal PSA test could drive a man to pursue unnecessary treatment or surgical procedures. Side effects, many of which are permanent, include urinary incontinence, erectile dysfunction, and bowel dysfunction.
Even so, proponents of the PSA test point out that prostate cancer is the most common cancer other than skin cancer in men, and that while some prostate cancers are slow developing, others are extremely aggressive. The proponents also note that only healthcare professionals can order surgery or other treatments and that not having PSA measurements removes an important data point that could help men and their providers assess the patient’s risk, evaluate all of their options. In some cases, including Berne Wooden’s, that treatment plan might include medical procedures such as radiation and surgery. For others, the best approach is to simply “watch and wait,” also called “Active Surveillance.” In either case, the decision is made by the patient, his family, and his doctor.
When evaluating the risks vs. rewards of a particular health screening, experts often look at the number of patients who would have to be screened in order to save one life. For prostate cancer, that number used to be very high. However, thanks to more accurate diagnostic techniques and looking at the impact of screening at longer time points, the ratio of screenings to lives saved is now in the same range for prostate cancer as it is for breast cancer. And while the Task Force recommended fewer mammograms for women, the USPSTF didn’t go as far as recommending that they not be done at all.
The big question is whether getting a PSA test will help men live longer. According to the USPSTF, “the precise, long-term effect of PSA screening on prostate cancer–specific mortality remains uncertain.” Dr. Steven R. Patierno, a professor at the Duke University Medical Center and Deputy Director of the Duke Cancer Institute, agrees that more research is needed, but he disagrees with the recommendation against using the PSA screening at all.
New studies are already showing that, as a result of the USPSTF’s recommendations, fewer men are being screened for PSA, and there is significant confusion among primary care physicians about whether or not to recommend screening to their age-appropriate patients. Using other tools, doctors are still able to diagnose prostate cancer. The biggest concern is that, instead of catching the disease before it becomes symptomatic, they may now start seeing patients for the first time in a later state of the disease or who have already developed severe symptoms. “If they wait until they have blood in their urine before they come in,” says Patierno, “at that point, treatment options are more limited.
There’s no question in Bernie Wooden’s mind that he would have been one of those men. He had none of the traditional symptoms of prostate problems: He wasn’t getting up multiple times at night to urinate; he didn’t have blood in his urine; he wasn’t overly tired or thirsty; he didn’t have erectile difficulties. In fact, he felt just fine. Without those regular PSA tests, his cancer might not have been detected until it was too late.
So What’s a Man to Do—Or What Should Women Do to Help the Men in Their Life?
One problem with the Task Force’s recommendation is that it didn’t adequately take into account high risk individuals, including African American men as a whole and any man who had a close relative (father or brother) who died of prostate cancer.
For Patierno, the big issue with the PSA isn’t overscreening or overdiagnosis. “It’s what you do with the information once you have a suspicious finding.” His own recommendations are generally in line with those published in 2015 by the National Comprehensive Cancer Network (NCCN).
- Men who are in a high-risk group (African American, family history of prostate cancer, or confirmed BRCA1 or BRCA2 genetic mutation) or who are interested in screening should get a PSA test and digital rectal exam at age 40. Those will be a baseline for future tests. If the PSA is 1 or greater, the patient should receive annual follow-ups. If the PSA is less than 1, the patient should have a follow-up screening at age 45.
- All men 50 and over should have PSA screening, with the frequency guided by PSA levels. Increasing evidence indicates that if the PSA level is less than 1, the chance of dying from prostate cancer is negligible. But if it’s between 1 and 3, the risk is much higher. Those men should get “active surveillance,” which means regular PSAs (usually no more than once every six months) to track whether or how quickly the disease is advancing. The only way to do that is if you have a baseline test. Increasingly, Active Surveillance protocols include more sophisticated imaging methods of detecting prostate cancer and distinguishing aggressive from indolent prostate cancer.
- As a diagnostic tool, PSA testing is most effective for men 55-69. Older men (over age 75) or those with a life expectancy of less than 10 years should probably discontinue PSA screening.
If the results of the PSA concern the healthcare provider, it’s time for a heart-to-heart to determine the best course of action. The first step will undoubtedly be to confirm the PSA results with a digital rectal exam (DRE), MRI, ultrasound, or, in some cases, a biopsy.
As far as treatment, in many cases, it starts with active surveillance. Beyond that, “we’re getting more and more sophisticated in our ability to identify whom to treat, whom not to treat, and what treatments to choose,” says Patierno.
Bernie Wooden suggests that if a man is referred to a urologist or other specialist for additional tests, he take a relative or close friend along. “After the doctor said the word ‘cancer,’ I didn’t hear anything else,” he says. “Fortunately, my wife was paying close attention and she was able to fill me in after we got home.”