Prostate Screening: What Should You Do?

March 4, 2010— -- In the words of that great philosopher, Yogi Berra, "This is like déjà vu all over again."

Maybe yes, maybe no.

If you assume that the new guidelines for the early detection of prostate cancer released Wednesday by the American Cancer Society don't offer anything different compared to the last major revision of the guidelines in 2001, then you may be missing some important messages about prostate cancer screening.

And you may miss what I consider the most important message of all: prostate cancer is so common in men age 50 and over that finding it by prostate cancer screening may be nothing more for most men than a fortuitous "random walk." As I learned myself, even with a perfectly normal PSA there is a real possibility that you have prostate cancer. Whether you need to find it or not is the heart of the issue.

Prostate cancer is clearly a major health issue in the United States. The American Cancer Society estimated that in 2009 (the latest year for which statistics are available) 192,280 men were diagnosed with prostate cancer, making it the most common form of cancer in men. Deaths from prostate cancer in the United States for 2009 were estimated to be 27,360, underlining the fact that many more men are diagnosed with the disease than die from it.

That's the relatively easy part of the discussion. The hard part -- as has become all too obvious to many over the past year through the controversy caused by the release of two studies that were supposed to answer the question of whether detecting prostate cancer early really made a difference in survival -- is whether prostate cancer screening really makes a difference in survival.

So controversies exist about what to do regarding the early detection of prostate cancer in men and whether getting a blood test called a prostate specific antigen (or PSA) with or without a rectal examination is something that men should do to save their lives.

Lo and behold, the evidence isn't clear on this topic, despite the fact that we have been vigorously administering PSA tests for about the past 20 years, and are busy every day in this country lopping out and radiating prostates to treat prostate cancer, leaving many of those men with serious long-term consequences like decreased sexual function and urinary incontinence.

Given all of this uncertainty and inconsistency of the evidence, you would rightly ask, "What does the American Cancer Society recommend men should do when it comes to that annual rite of a PSA blood test to find prostate cancer early?"

So here are the major recommendations from the guidelines:

Asymptomatic men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after receiving information about the uncertainties, risks, and potential benefits associated with screening.

Men at average risk should receive this information beginning at age 50. Men at higher risk, including African Americans and men with a first-degree relative (father or brother) diagnosed with prostate cancer before age 65, should receive this information beginning at age 45. Men at appreciably higher risk (multiple family members diagnosed with prostate cancer before age 65) should receive this information beginning at age 40.

Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources.

Patient decision aids are helpful in preparing men to make a decision whether to be tested.

Prostate cancer screening should not occur without an informed decision-making process.

Asymptomatic men who have less than a 10-year life expectancy based on age and health status should not be offered prostate cancer screening.

For men who are unable to decide, the screening decision can be left to the discretion of the health care provider, who should factor into the decision his or her knowledge of the patient's general health preferences and values.

Let me emphasize a couple of key points in these guidelines, in an effort to reduce confusion over what they say and what they don't say.

Most important, the American Cancer Society doesn't recommend routine screening for prostate cancer, and has not since 1997. There is simply insufficient and conflicting evidence to say whether or not PSA tests really make a difference and save lives. Some evidence says, "Yes it does," other evidence says, "No it doesn't," and some evidence is still too early to say for certain one way or another.

Bottom line, this picture is not clear, so we can't say yes or no as to whether screening is right for you.

So what do you do?

You and your health professional need to have a talk about the pros and cons of screening. You need to understand the possible benefits and harms, and what the evidence shows. Then you can make an informed decision about what is right for you. You may weigh the evidence and conclude that you want to be screened with a PSA test, or you may weigh the evidence and say that you don't. And if you can't make up your mind, the guidelines recommend that your health professional take your personal considerations into account and make the decision for you.

"But wait a minute," you say. "I go to my doctor or other health professional for an office visit these days, and I am lucky if I get to say hello before she/he moves on to the next patient. How the heck are we going to have that discussion? Great theory; lousy practice."

That's where the modern age of technology comes in.

Valuable decision aids are available on the Internet which have been shown to make the process more reasonable and efficient -- and allow you to move at your own pace in learning about prostate cancer screening benefits and risks. You will need an Internet connection, or you can call us at 800-ACS-2345 and we can offer you some help and guidance. Information is also posted on our Web site at www.cancer.org.

"But wait another minute: my local hospital has free screening. Isn't that a reasonable thing to do? Just go to my local grocery store parking lot, find the PSA van when it is there and get a test? Why shouldn't I do that?" you might ask.

Here's where we are probably at odds with a number of people who believe they are doing good by giving men mass screening in convenient locations.

Our guidelines are pretty straightforward on that one: unless you are someone who simply has no other access to medical care because you can't afford it, mass screening doesn't offer individualized counseling and education about the benefits and risks of PSA testing, so it should not be offered. And for communities that are disadvantaged, an effort must be made to provide that education and follow-up.

In other words, in our opinion, mass screenings at health fairs, or local parking lots or wherever are not a good idea. They certainly don't meet the recommendations in our guidelines that men have a direct discussion with their health care professional to discuss benefits, risks and harms of screening for prostate cancer. And let's be clear: although the benefits are uncertain, the risks and harms of treatment are real.

Because this is such an important issue, here is the actual text from the guideline:

"On the basis of these concerns, the ACS discourages participation in community-based prostate cancer screening programs unless they can provide adequately for an informed decision-making process and appropriate follow-up care. These programs have a special obligation to provide high quality, objective, informed decision making either through interaction with trained personnel or through the use of validated, high-quality decision aids appropriate to the target population. Moreover, it is incumbent on such programs to assure that participants with abnormal screening results receive appropriate counseling and follow-up care. Because virtually all men age 65 years and older have health insurance through Medicare, they should be discouraged from participating in community-based screening programs and should be referred to a primary care provider."

There is another "wrinkle" to the new guidelines that will be important for men to know, and it may also be somewhat controversial.

Most men who get PSA testing believe they should have the test every year. Putting aside the issue of whether PSA testing is right for you, the reality is that the evidence does not support the need for doing the blood test annually. Instead, if your PSA is below 2.5, the new guidelines recommend that you have the test every other year in the event you choose to pursue screening for prostate cancer.

The guidelines also maintain a recommendation that a PSA of 4.0 or greater needs to be evaluated. Over the past number of years, however, there has been a lot of discussion about the true "normal" level of PSA which requires further evaluation by a urologist.

As a result of that discussion, the guidelines recommend that doctors and patients make an individual decision as to whether a PSA between 2.5 and 4.0 requires further evaluation. Those are traditionally normal values, but you and your doctor should discuss whether they need to be looked at further by a specialist.

One of the factors that we use to make a decision whether that evaluation should be done was something called PSA velocity. In simple terms, PSA velocity refers to how quickly the PSA level increases year over year. If it's too fast, a doctor was supposed to recommend evaluation for possible cancer. If it was a small steady increase, then you could wait before moving on to ultrasound and biopsy.

In the new guidelines, the expert panel concluded that PSA velocity simply isn't useful enough to make a decision one way or the other. To some degree, that is a function of the PSA test itself which can vary considerably from test to test and day to day for a number of reasons. The PSA test is simply not accurately reproducible day to day, so its value is not as precise a number as some people believe. So whether or not your PSA is going up at a certain pace doesn't help make the decision about whether you may have prostate cancer.

Why are we having all of this trouble figuring out whether or not PSA works?

To some degree -- as already mentioned -- it is simply a matter that the evidence is in conflict at this time. Maybe with another couple of years follow-up on the major studies we will have more clarity in what they are trying to tell us. But right now, we are not there.

There is another and very important bit of background, and that is that many of us -- even those with perfectly normal, low value PSA tests -- harbor cancer in our prostate glands. We get a normal PSA blood test, think we are home safe for another year, yet deep inside the cancer is lurking.

The good news is that most of these cancers are indolent; that is, they won't cause us a problem. But for some of us, they may be high grade and not yet "visible" with the PSA test.

The reality is that prostate cancer is a disease of aging, one that actually starts at a very young age and continues to increase in frequency as we go from 40 to 50 to 60 and on. In simple terms, if you are a man, there is a possibility if not a probability (depending on your age) that you have a cancer in your prostate.

Let's talk real life here for a moment.

Yours truly has been blessed with a very normal PSA value (less than 1.0) for many years. Last year it shot up, and being the consummate professional that I am, I was scared. A trial of antibiotics, a repeat test, and -- good news -- the PSA dropped a bit.

Being the typical doctor that I am, I didn't find the time to go back and get my PSA repeated last August. Instead, I decided to let the anxiety build and build and build until a couple of days ago when I finally relented and got the repeat PSA test.

The good news was that it was back down to its very normal level of past years. And, to be truthful, I was relieved.

That relief only lasted for a day, since as I prepared this blog I decided to take advantage of one of the tools contained in the guideline which lets a man take his specific information (including his PSA and body mass index among other data) and make an estimate of whether he has cancer in his prostate.

What I found was instructive to me and I suspect may be to you as well, since despite my very, very normal PSA for a man of my age, my risk of having a prostate cancer is 14.1 percent. The risk of having a biopsy-detectable high-grade prostate cancer (that's the bad kind) is 1.3 percent. And that would be the same percentage for any other man out there who is my age, my size, and has a low PSA.

So now what do I do? Do I continue getting PSA's every year, the evidence notwithstanding that it may not do any good? Or do I go and get a prostate biopsy just for the fun of it?

My case isn't unique, because the reality is that for many of you men out there, if we stuck your prostate often enough with enough biopsy needles, we would stand a reasonable chance of finding cancer in your gland as well.

That is the crux of the dilemma: we have a blood test that is modestly accurate, but we don't know if it really makes a difference. And a normal value gives us false comfort that we do not harbor prostate cancer in our bodies, when in fact that may not be the case -- especially as we get older.

So it's back to square one: you make your decision on whether you want to be screened based on your own values and what type of person you are. But you must have the discussion and make the decision, since having your doctor say "just do it" is no longer sufficient unless you are part of the process.

No, we haven't made the situation any easier. But we have told you what the evidence shows. Now it is up to you to take the next step and have the conversation.

Len Lichtenfeld is deputy chief medical officer of the American Cancer Society. You can view the full blog by clicking here.

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