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Doctors differ on prostate screening

By Helena Oliviero and Steve Visser
The Atlanta Journal-Constitution

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  • By the numbers

    Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society’s estimates for prostate cancer in the United States for 2013 are:

    • About 238,590 new cases of prostate cancer will be diagnosed.

    • About 29,720 men will die of prostate cancer.

    • Prostate cancer can be a serious disease, but most men diagnosed with prostate cancer do not die from it. In fact, more than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today.

    • About 1 man in 6 will be diagnosed with prostate cancer during his lifetime.

    • Prostate cancer occurs mainly in older men. Nearly two thirds are diagnosed in men age 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 67.



Prostate screening tests detect prostate cancer early, but questions about whether the tests do more harm than good have made them one of the most hotly debated areas of medicine.

Some doctors believe testing for PSA, which stands for prostate-specific antigen, leads to unnecessary, costly and even harmful medical procedures because so many early diagnoses are slow-growing cancers that don’t require immediate treatment. But men typically demand care once they hear the C-word.

Those on the other side say PSA screening remains a valuable tool for detecting cancer early and saving lives.

The American Urological Association reversed course this spring and no longer recommends routine screening for men 40 to 54 years old, who face an average risk of getting prostate cancer. It said testing should be considered primarily for those 55 to 69. Even then, a PSA test should not be automatic. Men should talk to their doctors about the benefits and risks and “proceed based on their personal values and preferences,” the association recommended.

The urology group’s announcement followed the 2011 recommendation by the United States Preventive Services Task Force, arguing against routine screening in healthy men because it often leads to unnecessary biopsies and surgery as well as life-altering complications such as impotence and incontinence.

A problem with screening is that PSA levels can be high, indicating cancer, even when a man doesn’t have it. Another issue is that if a biopsy detects cancer, it is often very slow-growing and, as cancers go, relatively benign.

In other words, a PSA test was taking healthy men and turning them into cancer patients who underwent radiation therapy, surgery and other invasive procedures for something that would never cause death or even lead to any symptoms.

But even seemingly benign cancer can turn serious. And some men want to turn back any risk of cancer immediately.

Benefits vs. harm

Dr. Otis Brawley, chief medical officer for The American Cancer Society, has long called for more caution with prostate cancer screening, speaking against mass screenings such as the ones offered by health companies at shopping malls.

Many patients, he said, don’t fully realize the potential complications associated with PSA testing.

“My whole campaign has not been one that men should not be screened,” he said. “Let the man know the pluses and minuses, and what we know about the disease and the screening of the disease and then let the man decide.”

That decision, he said, should be based on weighing the benefits versus potential harm of screening. Research of men ages 55 to 69 suggests that PSA screening may prevent one death from prostate cancer for every 1,000 men screened at two- to four-year intervals over a 10-year-period. At the same time, many men who get the screening will be harmed because treatments can lead to health complications. Even a biopsy poses a risk of infection, for example.

Doctors may recommend “active surveillance” for men with low-risk prostate cancer tumors, in which the tumor is regularly monitored rather than treated. But getting patients to watch and wait is a difficult.

Dr. Martin Sanda, chairman of the Department of Urology at Emory University School of Medicine and director of the Prostate Cancer Center in Emory’s Winship Cancer Institute, said a patient’s decision about whether to monitor the low-risk cancer or undergo treatment often depends on how the information is presented.

The key, he said, is explaining that the biopsies not only detect aggressive cancers that need immediate treatment but also pick up cancers that are “quasi-cancer” and safe to watch rather than treat immediately.

But not all doctors are entirely comfortable with the concept of waiting and watching.

“These so-called quasi-cancers may not be a problem at all. And there’s also the possibility these quasi-cancers can spread,” said Dr. Marc Harrigan, a primary care physician at Piedmont Hospital. “You’ve got to put yourself in the shoes of the patient: ‘Do I want something inside of me?’ I mean, how comfortable would I be as a patient knowing there is a cancer inside of me that can grow at any time?”

Sanda remains an advocate of screening – which includes not only the PSA blood test but also the digital rectal exam. He sees firsthand what can happen when prostate cancer is not caught in the early stages.

“I see patients every month who are in their late 40s and early 50s and their cancer is too far along, and we can’t do anything to treat them,” he said.

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