PROSTATE CANCER SCREENING - WHO SHOULD DECIDE

Wed, 31 Mar 2010 06:36:48 MST

Michael D. Lutz, M.D. During the recent past, significant concern and debate has arisen as to the role of prostate cancer screening including its benefits, risks, and potential pitfalls. Although discrepancies exist between the American Cancer Society (ACS), the American Urologic Association (AUA), and the Prostate Conditions Education Counsel (PCEC), there also is a significant commonality of thought and reasoning for the proper role of the early detection of prostate cancer. In 1989, approximately ten years after the discovery of prostatic specific antigen (PSA), prostate cancer became the most commonly diagnosed cancer, as well as the second leading cause of cancer death in American men. It was also in 1989 that the Prostate Conditions Education Counsel (PCEC) instituted Prostate Cancer Awareness Week within the United States, publicizing the need and initiating a national prostate cancer screening program utilizing the digital rectal examination and serum PSA blood test. As a result of such efforts, there has been a documented decline in the prostate cancer mortality rates, not only in the United States, but as well in other countries that elected similar efforts and prostate cancer screening programs. Recent data released from the European randomized study of screening for prostate cancer (ERSPC) has demonstrated that screening for prostate cancer reduced disease specific mortality by 20%. More recently, the American Cancer Society (ACS) has revised its screening guidelines for prostate cancer. The ACS guidelines are neither a statement against prostate cancer screening nor a statement for screening; rather, they are a statement for informed or shared decision-making. The ACS believes that there are definite uncertainties, risks, and potential benefits regarding the efficacy of prostate cancer screening. They presently recommend that asymptomatic men who have at least a ten year life expectancy to have the opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the risks and benefits. The American Urologic Association (AUA) stands in support of prostate cancer testing. The AUA does not advocate universal annual PSA testing for all men, nor does it support routine prostate biopsies. Present research demonstrates that a PSA above a certain level at age 40 is a stronger predictor of prostate cancer risk than family history or race. It is the American Urologic Association's feeling that the recent debate is inappropriately focused on the PSA test itself, and rather we should be focusing on how the test results are being interpreted and impacting proper diagnostic decision-making. As a physician, we believe in the Hippocratic injunction primum nocere (first, do no harm). This phrase is particularly relevant when dealing with a healthy person and the concept of routine cancer screening. According to Wendy Poage, President of the Prostate Conditions Education Counsel, "The main confusion today in prostate cancer centers around two key issues, when to be screened and what to do with the screening results". A screening test fundamentally differs from a diagnostic test in its intent and potential consequences. While a diagnostic test such as a prostate biopsy will likely uncover a specific disease such as prostate cancer, a screening test such as a PSA, is designed to gauge the chance of harboring the underlying disease. Therefore, a diagnostic test necessarily follows the screening test in order to determine whether the disease truly exists. With regards to prostate cancer, the PSA represents the screening test, and the prostate biopsy, the diagnostic test. Although we know that the prostate biopsy is not absolutely definitive in effectively sampling the entirety of the prostate gland, nothing in medicine is ever perfect. It should now be apparent after comparing and contrasting the differing yet at times similar view points of the aforementioned organizations, the PSA blood test needs to be performed under specific guidelines, with the results of this screening test to serve as a probability of underlying prostate cancer risk. It is then that the patient, preferably with physician input decides his comfort level in taking the risk of not having a biopsy and not knowing whether cancer is lurking within his prostate gland according to Dr. Craig Niederberger. This concept is harmonious with the Prostate Conditions Education Counsel's statement, "Choose to know and know to choose". "Men should choose to know their PSA values, just as they would know their cholesterol, and know that there are many choices and variables in determining if they need a biopsy or treatment". The PCEC recommends a baseline prostate health assessment including a PSA and digital rectal examination for all men at 35 years of age. The PCEC recommends that men with a PSA less then 1 ng/ml be screened again in five years and men with a PSA between 1 to 2 ng/ml be screened every other year. For those who have a PSA greater than 2 ng/ml, they recommend annual screenings. All of the organizations mentioned within this article are all in agreement that screenings should not be performed if a man's life expectancy is less than ten years. The debate for prevention, early detection, and patient specific treatment options will have to remain unsolved at this time. However, all patients should "choose to know" by having proper "screening" performed and follows the previously mentioned guidelines which make sense at this time. "Knowing to choose" is the more difficult issue, and at this time rests between the patient and his physician.