Seriously, what is the deal with Prostate Cancer Screening: Do we do it or not?
Prostate is a common cancer in men. A blood test called PSA (prostate specific antigen) is usually elevated when prostate cancer is present. However, PSA may also be elevated when there is benign enlargement of the prostate, which is also common. Therefore, the PSA is not specific for detecting prostate cancer.
Doctors worry that a raised PSA level will cause significant anxiety to a patient because the patient thinks they may have prostate cancer , when the PSA is raised simply because of benign enlargement or benign prostatic hypertrophy.
On the other hand, men are worried about missing prostate cancer.
But what are the other concerns?
Doctors are worried about diagnosing cancer too early and causing more harm than good with their treatments, complications such as blood infections or sepsis from invasive biopsies, erectile dysfunction or urinary incontinence from surgeries and radiotherapies or anxiety from years of watchful waiting from a disease that men will likely die with rather than from.
Over the past few years, we have not been encouraging men to actively screen for prostate cancer unless they have risk factors or worrisome symptoms such as in their urine.
However, once again as medical technology and treatments advance it seems our advice needs to change. This is not because medicine is wrong. It is because it is an evolving and exciting field where research is always giving us new answers and options.
Now, we recommend that Australian men over the age of 50 years need to be aware of the risk of prostate cancer. They need to discuss the risks and benefits of testing and then decide with their doctor whether they will get tested, or not.
So, what are the risks and benefits and what has changed……
We now have multiple studies which show statistically significant survival benefits as well as reduction in metastasis or spread of disease from the prostate to other parts of the body when the cancer is treated early as opposed to simply monitored.
Our understanding of the PSA test itself has also increased. For example, if a PSA comes back raised, it must be repeated making sure that no sexual activity has occurred at least 4 days prior, as ejaculation can increase PSA and to make sure that there was no missed urinary tract infection.
A multi-parametric MRI (mpMRI) is now used prior to a biopsy. This is very good at diagnosing clinically significant prostate cancers and negates the need for a biopsy for many patients. Not only were the biopsies uncomfortable but they could also be dangerous as the biopsy can cause an infection. However, some patients will still need to go on to have a biopsy to confirm the diagnosis. This is now done via a different method which has a reduced risk of infection. There is a 25% rate of erectile dysfunction after a biopsy, but it is usually transient and resolves within 3 months.
One of our biggest concerns previously was overtreatment. This is because some prostate cancers are very slow growing and may not need treatment for some time. However, our ability to stage disease aggressiveness, likeliness to spread and cause premature mortality has improved with advancement of imaging techniques such as with PET scans (positron emission tomography). This means that low grade disease can be more safely monitored and when treatment is indicated, there are more options, and the treatment tends to be more focal and multidisciplinary in approach. It also means that more aggressive disease can be identified and treated earlier. This combined with the fact that medical therapeutics for more advanced disease have improved and have led to an improved quality of life and improved survival rates.
The key things that men need to consider when deciding whether they want to get a PSA test are:
Current evidence shows that a PSA test does help assess the risk of prostate cancer.
Do not do the PSA test unless you understand the risks and benefits of the PSA result.
If you have a life expectancy of less than 10 years, then a PSA test is probably not for you.
If you are over 50 years and have a life expectancy of 10 years or more, a PSA test is well worth considering but discuss with your doctor what you will do if the result is raised.
You might want to consider doing a PSA early than 50 years, say at 45 years if:
o You have a family history of prostate cancer, especially at a young age.
o You are of a high-risk ethnicity (African American or Caribbean)
o You have a family history of the BRCA (breast and ovarian cancer) gene.
References
1. Rashid, P, Ranasinghe, W & Zargar-Shoshtari, K. Prostate-specific antigen testing for prostate cancer: Tiem to reconsider the approach to screening: Australian Journal of General Practice. 52 (3): March 2023.