Controversy regarding prostate cancer screening has brewed for the past decade and really became a hot topic in 2012 when the U.S. Preventive Services Task Force recommended against routine screening for prostate cancer. The task force also recommended against mass screenings and, the next year, the American Urological Association affirmed this recommendation.
Unfortunately, aspects of these positions have caused confusion for both patients and physicians. Prostate cancer screening began in the early 1990s when the PSA test began being used. PSA stands for prostate specific antigen, and this chemical is leaked into the bloodstream by normal prostate cells and prostate cancer cells.
A man with prostate cancer has a rising PSA over time (measured by a blood test), but other prostate disease problems can also cause the PSA to go up. That is where the confusion lies.
But since we began to screen for and aggressively treat prostate cancer, nationwide mortality has gone down and survivability has improved from 67 percent to 92 percent in more modern times. Some physicians cite other factors in this improvement, such as general health improvement in older men and the increased use of aspirin and cholesterol-lowering drugs called statins. These medications have been linked to a lower rate of prostate and colon cancers.
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Most men with prostate cancer die of other things. This is true. But it is also true that if a man dies of cancer in the United States, it is more likely to be of prostate cancer than any other cancer except for lung.
And the third important truth about prostate cancer is that when it is in the organ and has not yet spread, it only rarely causes symptoms.
Therefore, the only way to find it is to look for it. The only way to look for it is to check what the prostate feels like (a digital rectal exam) and to look at trends in PSA values over time (PSA tests yearly or every other year) — the reason why men should consider talking to their doctor about their risks for prostate cancer.
The story of a recent patient of mine was dramatic but typical. He is 47, and one of his physicians ordered a PSA test. The PSA was elevated to 6.35 in early July.
After confirming this value, a biopsy was performed, and it showed medium-grade prostate cancer throughout his prostate.
In the last five to 10 years, urologists have been more and more frequently observing patients through the initial time frame of their diagnosis to see if the cancer will behave like an aggressive cancer or remain relatively stable.
Because of its volume, my patient’s cancer should not be “just” observed, and we are currently counseling him and his wife regarding options for definitive treatment.
Another patient who was 77 when we saw him initially last year had developed an aggressive form of prostate cancer despite his generally good health condition.
Without any symptoms his PSA had shot up from 3.7 in 2013 to 52 in 2014. His cancer has spread outside of his prostate gland into other areas, but his treatment will afford him a much longer and happier lifespan than if we had not diagnosed his prostate cancer then.
Some have used the relative advanced age of these patients (usually 65 and older) to argue against major interventions in curing the disease. Also, some physician groups and policy makers fear that the complication rates of treating prostate cancer with radiation or surgery outweigh the improvements in surviving the disease. Another double-edged sword in the discussions over screening: Having men come to an event where everyone gets screened usually fails to gather the tracking data over the years that would show an increase in PSA values.
But what if a concern is found with a digital rectal exam and PSA trend? The urologist should do a biopsy of the prostate, which is an outpatient medical procedure accessed via the rectum.
It is uncomfortable and not complication free, but there is not a better method as of yet. If cancer is found, it is the job of the urologist to prudently and practically guide the patient through a decision of cancer management that considers the patient’s health status and age.
The most important part of the new recommendations of the American Urological Association is that the individual patient has a discussion with his primary care doctor about all screening activities. The issue boils down to what the patient wants to do for his health.
Dr. Joseph Williams is a board certified urologist. He completed his surgical internship and residency in urology at the National Naval Medical Center in Bethesda, Md. He spent 10 years in the Navy and is a decorated veteran within the Persian Gulf during Operation Desert Storm and Desert Shield. Dr. Williams is a founding member of the Idaho Urologic Institute in Meridian. Visit www.idurology.com for more information.