Screening for prostate cancer — a prostate-specific antigen (PSA) blood test and a digital rectal examination (DRE) — is part of the yearly checkup ritual for many men. But is prostate screening necessary or even desirable? This unanswered question dominates the American Cancer Society’s (ACS) most recent update of its Guideline for the Early Detection of Prostate Cancer.1
The authors of the guideline do not outright recommend screening for any male patient. Rather, they clarify and elaborate in detail the shared, informed decision-making process that should determine whether or not screening takes place.
“In the case of colorectal and breast cancer, screening is much more likely to be helpful than harmful, so we recommend that patients have it done. With prostate cancer, we don’t have that level of certainty,” explains Durado Brooks, MD, director of Prostate and Colorectal Cancer in the Cancer Control Department of ACS. “The decision of whether to be screened is part of the discussion, not which test to use.”
The slow-growing nature of most prostate cancers, the risk that standard treatments pose to quality of life, and the lack of unequivocal evidence that screening for cancer actual reduces mortality underlie that position, Dr. Brooks says.
Who needs counseling and when?
One unambiguous recommendation is that men whose age and health status give them a life expectancy of less than 10 years should not be screened. “It serves no positive purpose,” Brooks said. Even in clinical trials that found mortality reductions with screening, it took seven to eight years for the benefit to emerge.
For most men, discussions about whether to screen should begin at age 50 years. Individuals at higher risk — black men and those with a father or brother diagnosed with prostate cancer before age 65 years — should start five years earlier. Men who have multiple family members diagnosed before age 65 years are at appreciably higher risk and should consider screening from age 40 years, the ACS guideline authors recommend.
Simply initiating such discussions may take effort. “Most men are used to going to the doctor and being told they have to have some test done. They are not accustomed to the idea that they themselves are to make the decision,” Brooks said.
For the man who defers to professional judgment, the clinician should factor in what he or she knows about the patient’s values and feelings about risk, sickness and health care, along with specific needs or health issues that may alter the risk/benefit equation.