The controversy regarding prostate cancer screening can be overwhelming. Screening is the process by which one tries to identify a disease, such as prostate cancer, when someone is without symptoms. The goal is early detection, which may lead to improved survival. Screening for prostate cancer is accomplished using the PSA blood test and digital rectal examination. The PSA value should be less than 4 to be normal. However, in reality, a normal PSA varies by age, with lower values for younger men, and higher values for older men. The digital rectal examination surveys the prostate for tumors.
Why does the United States Preventative Services Task Force recommend against PSA-based screening for prostate cancer? The USPSTF is a group of government-appointed primary care physicians whose charge is to determine whether or not a test is beneficial. In the case of prostate cancer, they made their decision based on two clinical trials, one conducted in Europe, and the other in the United States. The goal of the studies was to determine if prostate cancer detected by PSA and digital rectal examination led to improved survival. The US-based study had many flaws, which invalidated the findings. The European based study demonstrated a survival benefit of 21% 13 years after treatment. Thus, prostate cancer screening, and subsequent treatment, does improve survival.
The controversy results from the varied nature of prostate cancer. The majority of prostate cancer diagnosed in the US is slow growing and non-aggressive. These men die WITH, NOT OF, prostate cancer. In other words, it has no effect on their survival, even if not treated. However, there are men who have aggressive prostate cancer. Men with these types of tumors benefit from treatment. Prostate cancer is the second leading cause of cancer death in American men, with approximately 30,000 men succumbing to the disease every year. The goal of prostate cancer screening, then, is to determine not just if you have prostate cancer, but if you have the dangerous, aggressive, form.
One of the concerns regarding prostate cancer screening has been the risk of infection with prostate biopsy. Recently, tests have been developed to risk stratify men that may have aggressive prostate cancer, minimizing the risk of infection to those men who are unlikely to benefit from biopsy. The Opko 4KScore Test, for example, is designed to identify those men that are more likely to harbor “clinically significant” prostate cancer. These men are most likely to benefit from identifying their prostate cancer.
What makes the prostate cancer screening controversy challenging, and frustrating, is that there is no straight answer. The decision to undergo prostate cancer screening is nuanced and personal. The American Urological Association recommends that men discuss prostate cancer screening with their doctors.
We would be happy to sit with you and discuss this in greater detail, helping you determine whether or not screening make sense for you. To schedule an appointment, please contact our office (425) 775-7166.