Two new studies published on Tuesday in The Journal of the American Medical Association highlight that likely in accordance to USPSTF recommendations against screening, fewer men are being screened for prostate cancer and fewer cases of early state prostate cancer are being detected. The question is, if decreased screening is leading to a lower rate of diagnosis, what does this mean for the future of prostate cancer patients? The controversial revision of prostate cancer screening guidelines may be sparing many men of treatment, but this isn’t necessarily a good thing. Decreased screening doesn’t equate to the decrease in needless treatment, but more likely leads to missed opportunities to detect significant cancers at an early stage when they are still easily treated.
Despite our efforts in early detection, prostate cancer remains the second leading cancer cause of death in men, killing approximately 27,500 men this year. Tens of thousands of additional men suffer from the burden of painful metastatic prostate cancer, which can lead to bone fractures, the inability to urinate, spinal cord compression and renal failure. Since the widespread adoption of PSA screening in the early 1990’s, however, there has been a 39% reduction in prostate cancer mortality rates.
The controversial decision of the United States Preventative Services Task Force (USPSTF) to recommend against screening men for prostate cancer has led to a healthy debate regarding the utility of the early detection of this cancer. Advocates for men’s health and PSA screening are discounted for over treating and over diagnosing the cancers that may or may not be harmful. The evidence suggests that PSA screening has a benefit, but is not being used optimally. In 2009, the USPSTF was attacked when they recommended against mammograms for women between 40-49 years of age. They argued that too many women were being subjected to unnecessary biopsies to justify the patients whose lives were saved by the mammography. Many criticized the decision, stating it was akin to health care rationing. Similarly these new recommendations for prostate cancer reflect a growing concern that PSA screening is resulting in unnecessary treatment without impacting overall survival, but the jury is still out on that.
PSA screening may result in over-diagnosis, but that does not necessarily mean over-treatment. This is where the experience of the doctor comes into play. As Dr. David F. Penson of Vanderbilt University Medical Center said in the New York Times, “Rather than issuing a blanket recommendation against screening, it would be better to ‘screen smarter’ by testing most men less often and focusing more on those at high risk.” High risk men include, but are not limited to, men of African American descent, and men with a family history of prostate cancer. These groups should begin screening at age 40, followed by annual tests.
This disease is not entirely benign, and the PSA test is not a perfect test. It is not capable of determining which cancers will progress and which are clinically insignificant. Rather than taking the drastic step of eliminating PSA screening entirely, modifying its application can maximize benefit while reducing overtreatment and adverse side effects. This is why it is important to not just look at single test result, but to also look at PSA trends, co-morbid conditions, overall life expectancy, and understand patients’ treatment goals.
The debate over PSA screening has highlighted the importance of the need for physicians to practice individualized medicine rather than reflexive medicine. It is true that PSA is not an appropriate test for men of all ages, but these decisions should be based on each individual patient. PSA testing does not automatically lead you down the road to treatment and information is better than ignorance. The USPTSF is creating a dangerous proposition for healthy men. Prostate cancer is a mostly asymptomatic disease, so if we tell men not to get screened we’re essentially saying, ‘Yes, you may very well get prostate cancer and, yes, it might become painfully metastatic, but wouldn’t it just be easier not knowing?’
The ability to make informed decisions and accurate interpretations, comes from education. Because PSA tests are not necessarily straightforward, simple or easy diagnostic tools, knowing your risk factors and tracking the changes in PSA can help you make informed decisions about your health. To use treatment side effects as justification for not testing seems illogical when your life could be on the line. Furthermore, sexual potency and urinary control are not guaranteed victims of prostate cancer treatment. Enhanced vision and dissection precision through robotic surgery allows an experienced surgeon to spare the nerve bundles that control these two important functions. For some men, the recovery period involves short-term sexual and urinary issues, but with early detection robotic surgery can cure men of their prostate cancer.