Screening for prostate cancer

Prostate cancer is currently the most diagnosed cancer (excluding non-melanoma skin cancer) among U.S. men. Most cancers are localized, meaning that they don’t metastasize and most grow slowly or not at all. No worries about those. Only about seven percent of patients have a disease that does spread—the cancer to worry about.

Screening for prostate cancer was approved by the FDA in 1986 and became widespread in the late 1980s and in the 1990s.Yet the approval occurred in the absence of evidence that early detection of prostate cancer leads to improved patient outcomes. Studies have shown a modest reduction in prostate cancer mortality with PSA (prostate-specific antigen) testing: Screening 1000 men may prevent deaths from prostate cancer in 1.3 men in the 13 years after initial screening.  The problem with screening is that it finds prostate cancer in some men who would never have had symptoms from their cancer in their lifetime. Treatment can cause complications without yielding benefit.

The point of screening is to find cancers that may be at high risk for spreading if not treated. The thing is, about three out of four men with a raised PSA level will not have cancer. A high reading can be caused by medications, urine infections, certain sports, and ejaculation. False positive readings, which are common in older men, can lead to unnecessary tests, such as biopsy of the prostate, and can cause men to worry about their health. Biopsies can be painful and result in infection and blood in the semen. (Men who are 70 or older should not be routinely screened. Men between 55 and 69 should make their own decisions about screening.)

Patients whose tests reveal localized cancer have two options: 1) Treat the cancer with radiation therapy or radical prostatectomy, or 2) “active surveillance,” which may include periodic biopsies, MRIs, and PSA tests. Research has shown that prostate cancer mortality is low, regardless of the treatment. Nevertheless, the patient and his doctor must weigh the trade-offs between the benefits and harms of treatments. Harms include urinary incontinence, erectile dysfunction, and bowel dysfunction. Considerations about what to do include the patient’s wishes, remaining life expectancy, and the risk of progression to metastasis and death.

I’m glad I’ll never have to think about this—for myself, anyway.

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