The lifetime risk of prostate cancer diagnosis is about 16%, but the lifetime risk of dying from this disease is less than 4%. Because of this, it has been suggested that screening all men for this disease may lead to over detection and over treatment of the disease. Over detection refers to the ability of a screening test to identify a condition that would have remained silent or not affected the patient during his lifetime. This is in contrast to over treatment, which may result in the reduction of quality of life caused by the treatment of a disease. For example, having unnecessary surgery.
Studies conflict at this point. In one study, there appears to be a modest reduction in prostate cancer mortality among those screened for prostate cancer when compared to those that are not. However, in another study, there was no difference in prostate cancer deaths when comparing men that were and were not screened. So we don’t have an answer yet and at this point; therefore, researchers cannot state that screening is associated with more benefit than harm.
Here are some important facts to know about prostate cancer screening:
- Screening with PSA (prostate specific antigen- a blood test specific to prostate irritation) detects cancer at an earlier stage than if no screening is performed
- Prostate cancer screening might be associated with a decrease in the risk of dying from prostate cancer; however, evidence is conflicting
- For men whose prostate cancer is detected by screening, it is not currently possible to predict which men are likely to benefit from treatment or how aggressive the cancer is
- 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 (digital rectal exam) can produce false-positive (suggest cancer is present when it actually is not) or false-negative (suggest cancer is not there when it actually is) results
- Abnormal results from screening with PSA and DRE may require prostate biopsies, which can be painful and lead to complications
- Not all men whose prostate cancer is detected require immediate treatment
We know that using both the PSA and DRE detects more cancer than either the PSA or DRE alone. One way to think about it is to designate PSA for early detection of the disease. If the PSA is positive, a DRE is needed to confirm cancer.
There are 3 main bodies that have provided screening recommendations:
- American Urological Association (AUA)
- American Cancer Society (ACS)
- United States Preventative Services Task Force (USPSTF)
These governing bodies do not agree on their recommendation, therefore, it can get very confusing for patients and providers! Here I will discuss what each of the governing bodies recommends for prostate cancer screening.
The AUA strongly supports that men be informed of the risks and benefits of prostate cancer screening. They recommend PSA screening to well-informed men who wish to pursue early diagnosis.
The AUA recommends that early detection begin at age 50 years for men at average risk of prostate cancer, and sooner for those men at higher risk (positive family history in a dad, bother or son, African American race). In order to identify this high risk group of men, they suggest obtaining a baseline PSA for all men in their 40s. Typically, men at high risk will have an elevated PSA at this point.
The ACS suggests “informed decision making” with respect to prostate cancer screening for all men expected to live more than another 10 years. They suggest that information should be provided to patients in order for them to make an informed decision (and the information that we should provide is contained in this article!).
As far as who should undergo screening, the ACS recommends that all asymptomatic men who have at least a ten-year life expectancy should consider being screened. Men at average risk should consider screenings beginning at age 50. Men at higher risk (African American men, men with a first degree relative diagnosed with prostate cancer before age 65), should receive consider screenings beginning at age 45. Men at very high risk (multiple family members diagnosed with prostate cancer before age 65) should consider being screened beginning at age 40.
The ACS also recommend against screening men who have less than a ten-year life expectancy. Life expectancy is gauged by age and current health status.
USPSTF (2008) (Click Here to Read the New Update! (2011))
The USPSTF has two main recommendations with respect to prostate cancer. They state
“Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years”.
This is because there is insufficient or conflicting evidence to sway them one way or another. So we will have to wait and see what the research tells us.
The second recommendation is to “not screen for prostate cancer in men age 75 years or older”.
However, we have to take this recommendation specifically with a grain of salt. Not all 75 year old males have the same life expectancy! We all can think of two men at age 75, one who can run marathons and the other who may not be as healthy. The wording of the AUA and ACS recommendations are more individualized to each patient.
In summary, there are no hard recommendations regarding prostate cancer screening. Therefore, work closely with your primary care physician to determine when screening is appropriate for your individual case.