“Mass screening is not the right way to go,” Gerald Andriole, MD, chief of urology at the Siteman Cancer Center. “We have to take a more nuanced approach to who should be screened in the first place, and how intensively he should be tested.”
“The data are fairly compelling right now that looking for prostate cancer in every man merely because he is over 50 could actually be doing more harm than good. That approach has a little or no effect on mortality.”
The main reason for the recommendation to avoid general mass screening is that it can lead to over diagnosis and over treatment.
“If a man has PSA testing done on an annual basis, his chance of being diagnosed with prostate cancer is six to seven times greater than his chance of dying from it,” says Dr. Andriole. “And, because PSA can be elevated with any inflammatory process and even with a benign enlarged prostate, known as BPH, many men without cancer undergo unnecessary biopsies of the prostate.”
Dr. Andriole says with mass screening for prostate cancer there are “winners and losers.” “Some men clearly benefit from early detection and early treatment, but other men are losers,” he says. “They are diagnosed with a cancer, undergo unnecessary treatment and have side effects, and they go through all pain and anxiety associated with having cancer.”
For example, if a man finds he has an elevated PSA, gets a biopsy and finds out nothing is wrong, the patient has suffered unnecessary anxiety, unnecessary procedure, unnecessary pain and unnecessary cost.
According to Bruce Roth, MD, Siteman Cancer Center oncologist specializing in prostate cancer, two main factors increase risk.
“One, African-American males have the highest incidence of prostate cancer in the world and two, having a first degree relative with diagnosed prostate cancer increases risk,” he says. “There’s no way to make recommendations on a broad basis. You need to put it in the context of the patient’s overall health and the person best able to do that is the patient’s primary care physician.”
Overall Drs. Andriole and Roth both say patients should talk with their primary care doctor about PSA screening and if it’s right for them. “A patient who has a relationship with a doctor would then be in a position to understand what his future risk of prostate cancer is and how worried he in fact should be,” says Dr. Andriole.
Tailoring the intensity of screening in this way can reduce over diagnosis and over treatment of small, non-life-threatening cancers. Most men diagnosed with prostate cancer do not die of the disease and there is concern that treating a non-fatal disease aggressively does more harm than good.
“Lifelong incontinence, impotence, lots of other potential complications from treatment,” says Dr. Roth. “If they weren’t destined to die of prostate cancer then they haven’t been helped by screening, they have been harmed by screening.”
That’s why the American Cancer Society recently changed their screening recommendations, encouraging men to talk with their doctor before getting screened with PSA saying, “men should discuss the uncertainties, risks and potential benefits of screening for prostate cancer before deciding whether to be tested.”
“Approaches such as these will hopefully make the next 20 years of PSA based screening better than the first 20,” says Dr. Andriole.
For more information about prostate cancer risk, visit www.yourdiseaserisk.wustl.edu.