Last month saw the publication of an editorial by Nadler in Cancer presenting the case that prostate cancer screening should be initiated at age 40.
His argument is based on the concept that a baseline PSA at age 40 serves as a starting point for determining risk, and that this baseline allows the determination of PSA velocity and potential risk in younger men. The current National Comprehensive Cancer Care Network (NCCN) guidelines recommend an initial PSA at age 40 for men of all races, with the frequency of subsequent PSA tests depending on the initial PSA level. By contrast, Nadler suggests that, to be effective, PSA needs to be measured yearly beginning at age 40.
This is clearly an controversial issue, and whether the data justify annual PSA testing for the majority of men is certainly arguable. The question is how we balance the need to identify prostate cancer risk early in those at greatest risk for progressive disease compared to the equally significant need to avoid overtreatment of prostate cancer in men at minimal risk of progressive (as opposed to latent) disease.
The “New” Prostate Cancer InfoLink suspects that as yet we do not really have the data to come down on the side of annual testing for all starting at age 40.
Filed under: Diagnosis, Management | Tagged: screening
Until low morbidity treatments are developed to treat the large number of low volume cancers age 40 screening will detect, screening this early will result in much more harm than good. Orders of magnitude of more men will suffer psychologically from the diagnosis, and physically from the side effects of biopsies and mainstream treatments than are saved from premature death from prostate cancer.
Steve Z: Why not work to educate men about the implications of their diagnosis based on the tools and resources available today? If a 40-something-year-old man adopts lifestyle changes and becomes more aware of his health as he monitors his disease to help head off potential death and/or suffering, how is knowing you have cancer any worse then knowing you have diabetes or any other chronic condition?
Mike,
I have 2 major problems with your post:
1. We only have your interpretation of the Nadler editorial to go on. As I’m sure you know, there is no abstract available if you click on the link you gave, leaving one with nothing or the opportunity to spend money to gain access to the editorial. So there is no way to discuss Dr. Nadler’s position as he presented it.
2. Beyond that futility, is the pronouncement at the end of the post:
“The “New” Prostate Cancer InfoLink suspects that as yet we do not really have the data to come down on the side of annual testing for all starting at age 40.”
This is an opinion (”suspects”) without any substantiation.
Sorry, Mike, but neither you nor Dr. K has achieved such stature as to confer on your opinions the status of gospel. If The “New” Prostate Cancer InfoLink is going to pontificate, TNPCIL had better be prepared to back the opinion with facts. Or better still, TNPCIL should leave the pontification out and just report the news.
Rick Ward
Steve,
We all know you think PCa treatment, even it’s diagnosis, inevitably inflicts terrible harm on men. In your view, apparently, the only reason men should concern themselves with their prostate health is if there is some magic Ouija board that diagnoses PCa and some magic potion that cures it without any side effects, or even better that doctors could lay on hands and cure the patient.
But when you come out with a statement like, “Until low morbidity treatments are developed to treat the large number of low volume cancers age 40 screening will detect,” to put forth those views, I say to you once more, where are your specific citations for this statement? Specifically, what citations can you offer to back your statement about “low volume cancers” at age 40?
Rick Ward
I had been screened with the PSA assay since I was 37. My level then was 1.0 ng/mL. Screening @ 39 resulted in a level of 1.5 ng/mL. The response from the physician was “Don’t worry, we don’t even know how to use this assay yet to detect prostate cancer in young men.” When I was 42 and 45 I wasn’t told the results other than the physician told me that he would like to see my PSA level lower, but couldn’t feel anything, so don’t worry. I switched physician, had a PSA of 3.0 ng/mL when I was 47, 3.7 ng/mL 6 or 7 months later and referred to a urologist. I eventually was in contact with an experienced university-based urologist that indicated a biopsy was in order and that he was concerned about prostate cancer that was infiltrating and didn’t cause overt nodules.
The result was high volume prostate cancer that could have been caught earlier had the information known now been available then. So from a personal perspective, a baseline earlier with an interpretation of what the results mean for future disease risk would make a lot of sense. The advantage of detecting low volume disease is that the probability of having metastatic disease when diagnosed [early is] much, much lower and the chance of a permanent cure is concommitently higher.
It might be of interest in respect to Dr. Nadler’s editorial espousing 40 as the entry age for PCa screening to consult SEER (Surveillance Epidemiology and End Results), SEER Cancer Statistics Review, 1975-2005 for Prostate Cancer
http://seer.cancer.gov/csr/1975_2005/results_merged/sect_23_prostate.pdf
If you go to the above PDF, specifically Page 5, you will find
Table XXIII-4, PROSTATE CANCER (Invasive)
SEER INCIDENCEa AND U.S. DEATHb RATES, AGE-ADJUSTED AND AGE-SPECIFIC RATES, BY RACE
AGE-SPECIFIC RATES, 2001-2005
AGE AT DIAGNOSIS/DEATH:
40-44 8.7
45-49 40.2
50-54 136.4
Many “experts” are now comfortable with beginning PCa screening at age 45, which was a significant step down from the 50 that was itself a step down from the more traditional 60. So, too, is the step down to 40 years of age, but both steps have added measurably to the rate of combined incidence AND death of PCa. Sadly, SEER has lumped both the incidence and the deaths together to get these rates. Had they not, perhaps something could be seen in the death rate in each grouping that might lend credence to the reductions in screening start age.
Page 6 offers another perspective, though the age breaks are skewed:
Table XXIII-5
SURVIVAL RATES, BY RACE, DIAGNOSIS YEAR, STAGE AND AGE
5-YR RELATIVE SURVIVAL RATES, 1996-2004c
AGE AT DIAGNOSIS:
<45 94.5
45-54 97.5
55-64 99.5
It doesn’t help here that the span of years is much broader than in the incidence/death stats either, but consider this: since the generally accepted age for beginning PCa screening was at the least 50 years of age (most often 60) during this period, might the poor survival rates in younger groups be a result of not being “caught” by screening?
Presenting with symptoms (as was the way before PSA and aggressive screening) most often resulted in a diagnosis of more advanced PCa with poorer outcomes.
Not screening at 40 because of some misguided “rule” against screening at such a tender age denies those men at least the opportunity to decide for themselves what their course of action is to be if they are alerted to a problem with their prostate or if they are actually diagnosed with PCa.
Speaking as a PCa survivor “caught” in 1994, not driven by “evidenced based medicine,” I’ve been telling men for years to get a PSA and DRE beginning at 40, 35 if there is family history. Scientific? No less than the dictum of 50 and older, and at least driven by seeing too many men being diagnosed in their 40s, even in their 30s when there was a family history. Most thinking PCa survivors will tell men the same thing: 40.
Rick Ward
I have recommended that men get their INITIAL “baseline” PSA test at age 40, but NOT that they universally get ANNUAL PSA tests thereafter.
The frequency schedule of PSA testing FOLLOWING the initial one, in my layman’s opinion, should be based upon the results of the first PSA. An asymptomatic 40 year old man should have a PSA of no more than 1.0 ng/ml. If he falls in that range, he can wait as long as 5 years before repeating the PSA test, between 1-2.5 ng/ml = 2 years and higher than 2.5 = annually. These guidelines can be adjusted by the physician based upon other clinical findings.
My logic for starting PSA testing at 40 is to establish a baseline “normal” PSA for the individual, prior to the effects of BPH (Benign Prostate Hyperplasia (or hypertrophy) having a chance to seriously distort the norm. We are well aware that the trend in a series of PSA readings, is of significant benefit in evaluating the true significance of PSA changes. With a more reliable “normal” as a base for such determinations, the evaluations of such trends should be enhanced.
Is this recommendation perfect? No, of course not, but in my opinion, it is superior to any of the present recommendations for initiating PSA testing and follow-up scheduling. - John (aka) az4peaks@newPCa.org
I wonder why the urologist in Jim Crute’s case did not investigate an apparent higher than normal PSA rather than saying they do not know how to interpret the PSA in a man his age? Shouldn’t physicians be using judgment in making decisions rather than just blindly following evidence-based criteria? Unfortunately it seems that there is a denial even in the urology community that younger men can get prostate cancer.
From what I have read about evidence-based medicine, doctors are supposed to use their judgment and go outside the evidence based on the individual situation.
Maybe we need studies/trials about prostate cancer in younger men? It seems that work needs to be done on how to identify potentially aggressive or advanced cancer in the men under 50 or even 40. If the doctor did not know how to treat Jim then that means there is a big gap that needs to be filled. His story also shows the problem of the knowledge gap between the university-based urologist and the average community-based urologist, especially in treating men who do not fit the “normal”.
I believe that screening is not the real issue. Rather it is gaps in physician education or approach, Right now the emphasis is on screening when maybe it should be on appropriate treatment after diagnosis? Easier to sacrifice some men rather than looking at physicians and what they do after a PSA is done.
Kathy: It is certainly about physician knowledge and behavior. But it is also critically all about management of the individual patient as opposed to screening or treatment specifically.
I am sure that most of the advocates who have been around for a while have come across cases like Mr. Crute’s before, just as we have come across cases of men in their 70s getting radical prostatectomies when they had early-stage localized disease with Gleason scores of 6 and who died a year or so later from highly expectable conditions like cardiac arrest.
Evidence-based medicine is useless when it is used like a Betty Crocker cookbook and followed with slavish accuracy. All the more reason to tell every patient, all the time, “Find a doctor who is listening to you and who actually knows what (s)he is doing.”