Should Men Get Prostate Cancer Screening?

Two new studies on the PSA test may leave many men confused.

ByAudrey Grayson<br>abc News Medical Unit
March 17, 2009, 6:47 PM

March 18, 2009&#151; -- At 62 years old, Eric Larson is among an age group that many health organizations recommend get annual prostate test to detect signs of prostate cancer.

However, Larson opts out of the screening year after year.

The reason, he said, is that studies have not demonstrated that "there is any benefit [to the prostate specific antigen screening] and there is certainly a good chance the PSA [prostate specific antigen] screening leads to procedures with complications and without benefit."

And Larson should know -- he is a physician who serves as the executive director of the Group Health Center for Health Studies in Seattle Wash.

Like many other doctors, Larson has been waiting for years to see the results of two large trials in the United States and Europe to determine whether the screening for prostate cancer actually saves lives.

Now that the day has come and results are out, many doctors are left with more questions than answers on the benefits of regular prostate specific antigen screenings -- and Larson will continue to opt out of his own screenings.

Researchers for a U.S. study came to the conclusion that, after seven to 10 years of follow-up, men who got the PSA test were no less likely to die from prostate cancer than men who did not. A separate European study, on the other hand, suggested a benefit to getting tested -- albeit a disappointingly small one.

But perhaps the biggest burden of these inconclusive results lie with men Larson's age who are not doctors and are ultimately left to decide whether the PSA screenings are worthwhile to them. Worse, a positive result could force these men into an even more grueling decision -- what to do if the screening results show elevated prostate specific antigen levels.

Simple Test, Difficult Questions

The drawbacks to the PSA screenings are fairly well understood: Though the test can help to predict a man's likelihood of having prostate cancer, it cannot provide any information on how aggressive or serious the cancer is.

"The challenge we have right now is that when we find prostate cancer, we don't know whether it's a killer cancer or what has been termed a 'toothless lion' type of cancer -- one that a man will die with, not of," Dr. Gerald Andriole said during National Cancer Institute news conference Tuesday.

Get Your Questions Answered at the OnCall+ Prostate Cancer Center

"And we've made the mistake of tending to treat all of these patients aggressively," said Andriole, chief of the Division of Urologic Surgery at Washington University in St. Louis, Mo.

In order to avoid the pain, trauma and side effects of treating a non life-threatening, slow-growing cancer many experts recommend that patients with elevated PSA levels take a "watchful waiting" approach.

"My mantra is 'overdiagnosis doesn't have to result in overtreatment,'" said Dr. Mitchell Benson, a professor and chairman of the Department of Urology and Urologist-in-Chief at Columbia University Medical Center. "I think it's absolutely safe to watch people. This is increasingly being shown to be valid. [And] no treatment now doesn't mean no treatment later."

ABC News medical editor Dr. Timothy Johnson said patients should be fully prepared to have a lengthy discussion with their doctors about treatment options should the screening reveal elevated PSA levels.

"The bottom line is that if a patient [or] doctor decides to do a PSA test, they should be prepared [and] committed to a full discussion about the options -- including doing nothing -- if the test is positive," Johnson said.

Johnson also recommends that men who are first diagnosed with prostate cancer seek a second opinion regarding their options for treatment.

"I now routinely recommend that any man who has been told he needs treatment for prostate cancer seek a second opinion from a non-surgeon, non-radiologist resource," Johnson said.

According to Benson, there are general rules for treating prostate cancer that patients could benefit from understanding.

For the most part, any man younger than 65 whose cancer is determined to be aggressive by a biopsy should undergo treatment for the disease. On the other end of the scale, any man who is older than 75 with nonaggressive cancer "almost certainly doesn't need treatment," Benson said.

However, Benson said there is a "middle ground where some need treatment and some don't."

Benson explained that men between the ages of 65 and 75 are often faced with a difficult decision regarding whether to treat the disease, considering the relatively high chance that they would die of another cause before the cancer could kill them.

What Age Should Men Screen for Prostate Cancer?

Also included in this "middle ground" are younger men -- generally younger than 50 -- with nonaggressive forms of prostate cancer.

"We can't predict that the cancer will stay around and not be a problem for the rest of the 30 or 40 or 50 years of their life, but I would wager that 40 years is a long time for nothing to happen," Benson said.

It is precisely these patients in the "middle ground" who Benson believes would benefit most from watchful waiting on the disease. If these patients decide to forego immediate treatment, Benson asks that these patients return every 12 to 18 months for repeat biopsies.

According to Benson, about 90 percent of his patients choose not to take on treatment immediately when he explains the benefits and drawbacks of choosing the "watchful waiting" approach.

However, some experts say it has proven difficult to impossible to implement this strategy with every patient who receives a prostate cancer diagnosis.

"When dealing with cancer, emotions ... are often more influential than data," said Dr. Lee Green, professor of family medicine at the University of Michigan.

Green refers specifically to the reluctance of many patients to simply "do nothing" about their cancer -- even if delaying treatment for the disease could mean avoiding an extremely painful and unnecessary treatment.

"Our patients are taught to think of cancer as something to be removed immediately by any means possible -- surgery, chemotherapy [or] holistic medicine," said Dr. Geeta Nayyar, a assistant professor of medicine at George Washington University. "The challenge will be educating the public about why all cancers are not created equally."

To this end, some experts strongly urge greater patient education on the pros and cons of screening for prostate cancer.

"I don't think most patients are adequately informed, who are in screening clinics offered around the country by health-care organizations," said Dr. Michael Glode, professor and chair of the University of Colorado Cancer Center. "It may be impossible to fully explain the Pandora's box nature of screening. ... Screening programs should have better informed consent procedures going forward."

But beyond understanding the benefits and drawbacks of screening for prostate cancer, Benson said the most important thing a patient can do "is not to be scared into treatment because of the diagnosis."


Do you want to know more about prostate cancer symptoms, risk factors, tests or treatment? Visit the OnCall+ Prostate Cancer Center to get all your questions answered.

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