Clarification or Continued Confusion?
According to the American Cancer Society, other than skin cancer, prostate cancer is the most common among American men. About one man in every six will be diagnosed with prostate cancer during his lifetime. The good news is that prostate screening can help doctors catch developing cancer before it becomes life threatening and in the majority of cases, it can be treated successfully. That’s easy right? Screening leads to early detection, which leads to treatment, which potentially leads to a cure. Well, unfortunately it’s not quite that simple. To understand why prostate screening continues to be the topic of hot debate, even now after the recent release of new prostate screening guidelines by the American Urological Association (AUA), we have to understand the benefits and the limitations of the screening test.
This May, the American Urological Association released new guidelines for prostate screening. The guidelines make the following specific statements:
• PSA screening in men under age 40 years is not recommended.
• Routine screening in men between ages 40 to 54 years at average risk is not recommended.
• For men ages 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening, and proceeding based on patients’ values and preferences.
• To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over diagnosis and false positives.
• Routine PSA screening is not recommended in men over age 70 or any man with less than a 10-15 year life expectancy.
PSA or prostate specific antigen is a molecule specific to the cells that make up the prostate gland. Prostate cancer disrupts prostate cells and causes the release of PSA into the bloodstream. Doctors can check the level of PSA in a man’s blood with a simple blood test. The higher a man’s PSA level, the more likely it is that he has prostate cancer. Since PSA levels begin to rise early in the course of prostate cancer, the PSA test can detect prostate cancer before it becomes dangerous.
The problem is, that prostate cancer is not the only reason a man’s PSA level might rise. As a man gets older his prostate glands tend to enlarge. An enlarged prostate, as well as other common factors, such as a digital rectal exam or urine retention may also cause higher PSA levels. A PSA level of 4.0 or above is generally considered suspicious, but men who have PSAs well above 4.0 may not have cancer and men with prostate cancer may have scores below this level.
Because the PSA score alone is not sufficient for a solid diagnosis of prostate cancer and a subsequent biopsy, further examination is warranted. There are two forms of PSA, free and attached. An enlarged prostate (benign prostatic hyperplasia or BPH) and other non-cancer conditions may increase the free form of PSA, while prostate cancer is more likely to produce the attached form. Doctors can measure the free vs. the attached PSA to help determine if a prostate biopsy is needed. Other factors to be considered are the speed with which PSA rises over time (PSA velocity), and the relationship between PSA and the size of the prostate (PSA density).
The next step for a man whose screening tests have indicated a likelihood of prostate cancer is a biopsy. Once the biopsy is evaluated, a man diagnosed with prostate cancer still has a number of options to consider. Because the decision to treat prostate cancer is such a complicated and subjective one, Well-Being spoke to Patrick P. Daily, M.D., Urologist with Mississippi Urology Clinic.
“Prostate cancer is a very challenging disease to treat,” notes Dr. Daily. “No two cases are the same. It takes considerable experience and knowledge to counsel men and their families as to whether or not to be screened, to be treated, and to provide the latest options to those who have been diagnosed with an aggressive form of the disease.”
“When it comes to screening, I use the current AUA guidelines – and recommend screening for men age 55-69, and for high-risk men age 40-69,” Daily explains. “However, a majority of patients in our area are in the high-risk category with our predominantly African American population. African Americans have a much higher incidence of prostate cancer and higher incidence of more aggressive cancers.”
“The negatives of being screened are the risks of a prostate biopsy (bleeding, infection, pain), false positive tests, and over diagnosis,” Dr. Daily continues. “Over diagnosis is the true crux of the issue. It’s not really over-diagnosis but over-treatment that is most harmful. The positives of screening are that death rates from prostate cancer have dropped 40% in the PSA era. The new guidelines only take into account reduction in overall mortality rates from screening and not prostate cancer specific mortality. This is a tough issue because prostate cancer studies require long follow up (10-20 years) and it is tough to keep men in a study that long.”
One option men have is to closely watch the cancer to see if it gets worse. The downside of this option is the high degree of anxiety the man may experience and the chance of waiting too long to get treatment.
For those men who opt for some form of treatment, most of which have a high rate of success in curing the cancer, there are potential side effects to consider, such as blood clots in the legs or lungs, heart attacks, impotence or incontinence. However, robotic surgery has positively impacted treatment over the past ten years. Side affects from this surgical treatment are much less than with prior techniques, and many men are choosing this treatment option.
According to Dr. Daily, the decision to treat immediately or monitor the cancer over time is as individual to each patient as is the cancer itself. “To one man a 15 % chance that their cancer is aggressive will comfortably reassure them that they can be monitored, but to another, that risk would cause them to schedule surgery tomorrow,” Daily adds. “Men and their wives have a varying ability to cope with a cancer diagnosis and this is the biggest factor in determining what option they choose. I have the opinion that over-treatment can be resolved by better patient education and hopefully new genetic tests will help to educate men as to whether or not their cancer needs aggressive treatment.”
Dr. Daily sums up his take on the controversy around PSA testing and the dilemma of when and how to treat prostate cancer with the following.
“I consider the AUA to be the best resource for screening guidelines because they have the most experience in treating men with prostate cancer. My biggest challenge is articulating to a wide variety of people what the significance of their cancer is to their health and the time frame in which their disease will impact their life. There are so many factors involved, no man should make a decision without considerable conversation with his doctor, as well as honest and direct discussions with his partner,” Dr. Daily concludes.”
Patrick P. Daily, M.D., Urologist, with Mississippi Urology Clinic, received his doctor of medicine degree from the University of Mississippi School of Medicine. He completed his general surgery internship and residency in urology at the Medical University of South Carolina, Charleston, South Carolina. Dr. Daily is certified by the American Board of Urology.