Men have long been encouraged to get prostate cancer screenings, but there's insufficient evidence that the benefits of a PSA test outweigh the substantial risks associated with the screening.
That's why the American College of Physicians (ACP) announced new guidelines that recommend that men between the ages of 50 and 69 years old should discuss the limited benefits of the prostate-specific antigen (PSA) test with their physicians.
It's equally important that men understand the risks associated with this test, which can lead to additional testing and treatment that may not be necessary for slow-growing prostate cancers, the ACP said.
Routine screening not supported
"By and large, the data doesn't support routine screening because the outcomes aren't better. For the significant majority of men who have a relatively benign form of prostate cancer, that cancer isn't likely to give them problems in their lifetime," said Dr. David Bronson, president of the American College of Physicians, and a professor of medicine at the Cleveland Clinic.
"Men need to know that they have choices. Have a discussion with your physician. Have a long conversation about the pros and cons," Bronson suggested.
As many as one in six men will be diagnosed with prostate cancer in their lifetime, research shows. Yet, only less than 3% of men will die from the disease. Most of the deaths related to prostate cancer occur in men older than 75 years, according to the experts.
Screening for prostate cancer is easy. The PSA is measured through a simple blood test. Knowing what to do with the PSA result is far from simple, however.
PSA measures the level of prostate-specific antigen in the blood. In general, the higher the level of this protein, the more likely it is that a man has prostate cancer, according to the U.S. National Cancer Institute (NCI). But, not everyone with an elevated PSA has prostate cancer. And, PSA doesn't tell your doctor how aggressive a potential cancer might be.
Because of this uncertainty, if a man who isn't having symptoms has an elevated PSA after a screening test, the test is usually repeated. If it's still elevated, a man may choose to wait and have the test repeated again at a later date, or his doctor may recommend a prostate biopsy, according to the NCI. This is usually done through the rectum, using ultrasound to guide the needle. There's a risk of infection from this procedure. And, even with a biopsy, it's not clear which men have aggressive forms of cancer and those who have slower-growing cancer.
Treatment comes with risk
This uncertainty often leads men to choose surgery and other procedures in an attempt to eradicate the cancer.
"The word 'cancer' is very frightening. If you have cancer, you naturally want to get rid of it. But, treatments come with significant risks," Bronson noted. Potential risks from prostate cancer treatment include urinary incontinence, erectile dysfunction, anxiety and discomfort, according to the guidelines.
To prevent one death from prostate cancer, about 1,400 men would have to be screened, the guideline authors conclude. More than 100 men would have a false-positive PSA, and more than 100 men would be diagnosed with prostate cancer that might or might not need to be treated, and about half of those would experience a treatment-related complication, according to the NCI.
The ACP's first guideline recommends that physicians inform men between the ages of 50 and 69 years old about the risks and benefits of screening, taking into account each man's individual risk factors for prostate cancer and their life expectancy. In men who don't express a clear preference for screening, the ACP advises physicians not to use the PSA test.
The second guideline recommends against routine screening for men under 50 or over 69 years old, or men with a life expectancy of less than 10 to 15 years.
Screening has risks and benefits
"What the ACP arrived at after looking at our guidelines and others is that men should be given information about the potential benefits and known harms from prostate cancer screening," said Dr. Durado Brooks, director of prostate and colon cancers for the American Cancer Society.
"If men want to be screened, it's certainly within their right. But they need to know we don't have studies that clearly demonstrate that screening can alter the course of prostate cancer. And we don't have evidence that screening provides better outcomes," Brooks said.
"I think there's a great deal of confusion surrounding prostate cancer screening, in part because the message has been that people should get screened, and the idea that screening isn't always a good thing is relatively new," he added.
Both Bronson and Brooks said that men shouldn't be screened at health fairs or other free screenings unless they've had a discussion with their doctor already about the potential risks and the limited benefits of the test.
If you're showing any signs of prostate cancer, such as blood in the urine or difficulty emptying the bladder, then you need to see your physician for a diagnostic evaluation, rather than a screening test. However, these symptoms don't always mean prostate cancer either and will likely warrant a discussion of risks and benefits of the PSA test in this situation, too, according to Bronson. Men who are having symptoms aren't addressed in the current guidelines.
The new guidelines appear online April 8 and in the May 21 print edition of the Annals of Internal Medicine.
Learn more about prostate cancer from the American Cancer Society.
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