Ashutosh K. Tewari, MBBS, MCh
The Kyung Hyn Kim, MD Chair in Urology, The Mount Sinai Hospital
Chair, Milton and Carroll Petrie Department of Urology,
Icahn School of Medicine at Mount Sinai
What Every Man Should Know About Prostate Cancer Screening
Prostate-specific antigen (PSA)-based screening for prostate cancer has long been controversial. With guidelines changing on a regular basis and experts disagreeing over its use, determining whether or not to get tested can be confusing. Arming yourself with a better understanding of the issues can guide your decision-making process.
The Risks of Prostate Cancer Screening
Prostate cancer screening involves a blood test to measure the level of PSA, a protein released by a man's prostate gland. An elevated PSA can indicate prostate cancer, but can also be a sign of several harmless conditions. Such false-positive results can create alarm and cause many men to undergo unnecessary biopsies, which put them at risk of bleeding, infection, or other complications.
Another risk with PSA screening, which helps identify prostate cancer early on, is overdiagnosis. Often, prostate cancer grows so slowly that many men diagnosed with it are more likely to die of other causes before the cancer becomes fatal. But an elevated PSA test may lead them to undergo early, and probably unnecessary, treatment. Surgery and radiation, the mainstays of prostate cancer treatment, can have serious side effects, including erectile dysfunction and urinary incontinence (leakage).
Effects of a New Guideline
That's why, in 2012, the U.S. Preventive Services Task Force recommended against routine PSA-based screening for men of all ages, concluding that the benefits did not outweigh the harms. Two new studies published in The Journal of the American Medical Association show that this recommendation has had its intended effect: fewer men are indeed being screened and, therefore, fewer men are being diagnosed with early-stage prostate cancer. But is this good news?
The Task Force was on to something, but perhaps reacted too strongly. Addressing issues with PSA screening by rejecting it altogether has ended up minimizing the seriousness of prostate cancer. Prostate cancer still kills more than 27,500 American men every year. Reducing the number of biopsies and unnecessary treatments is a good clinical goal, but not looking for cancer at all is not the answer.
A Different Strategy
The question is how to find prostate cancer while it is curable, determine its severity, and treat it appropriately, while minimizing the harms of PSA screening. To do so, we don't need to test less--we need to test smarter. It is now possible to do this by augmenting PSA screening with new diagnostic tools that help prevent unnecessary biopsies and treatments, yet still catch aggressive cancers.
Prostate cancer is curable only when found very early. Evidence has shown that one man is prevented from dying of prostate cancer for every 1,000 men screened over a decade. It's true that not every patient needs to be treated, but if men are not routinely tested, we lose the opportunity to find prostate cancer early, and aggressive forms of cancer that do require treatment will be discovered too late to be cured.
New Tools Help Minimize Risk
When a basic PSA test reveals a high score, we can gather further evidence by combining more detailed variations of the PSA test with new types of blood and urine tests, sophisticated diagnostic imaging, and genomic analysis (study of a patient's genetic material obtained through blood or urine samples). Insurance covers these tests in most cases, with appropriate justification. The results help doctors determine if a biopsy is actually necessary and, when cancer is diagnosed, understand whether it needs treatment.
For example, magnetic resonance imaging (MRI) of the prostate can help pinpoint who needs a biopsy by showing whether the prostate tissue is normal or has potentially cancerous lesions. When a biopsy is required, MRI images can also help target the biopsy needles to the exact location, yielding precise diagnostic information. Combining imaging with genomic analysis of the biopsied tissue can tell doctors if a cancer is slow-growing or more aggressive.
The 'Active Surveillance' Option
The additional data provided by these advanced tools help doctors identify which patients are eligible for a wait-to-treat approach called "active surveillance." Rather than immediately undergoing surgery or radiation, patients on active surveillance are carefully monitored, typically through quarterly blood testing and digital rectal exams, annual imaging, and additional biopsies as needed. Men whose cancer never becomes a problem can avoid treatment and its side effects altogether. Those whose cancer is found to be getting worse and endangering their health can begin treatment while the cancer is still curable.
Talk with Your Doc
Choosing whether or not to be screened is a personal decision best made in consultation with your urologist, who can help you weigh the pros and cons and answer your questions. Discussing prostate cancer screening starting at age 45 is particularly important for men at higher risk--African Americans and those with a family history of prostate cancer. I encourage men between the ages of 50 and 70 who are at average risk to do so, too. (By age 70, the likelihood that prostate cancer would endanger your health over the rest of your life is small.) Be sure to ask your doctor to explain the newer approaches for minimizing biopsy and unnecessary treatments, while catching potentially lethal cancers while they are still curable.