It’s time to bury annual, mass, population-based prostate cancer screening

For nearly 20 years America has conducted a massive experiment based on an unproven hypothesis … that we could significantly reduce prostate cancer mortality rates if we gave every man over 50 a PSA test and a physical examination (using a DRE) every single year. But it’s not true, …  and it’s time to face up to that reality.

What absolutely is true, however, is that the availability of the PSA test and the increased use of that test over the past 20 years has been associated with (albeit not necessarily the sole cause of) a dramatic decline in the numbers of men diagnosed with advanced forms of prostate cancer and a continuing decline in the numbers of men who die of prostate cancer.

It would clearly be stupid, on the basis of the currently available information, to completely abandon the idea of prostate cancer awareness and to abandon the widespread use of the PSA test and the DRE.

What we need to start to do is seek a true middle ground that can be appropriately tested and evaluated. So what might that middle ground look like?

Let’s begin by making an assumption and then try to categorize the male population of America into some specific and well-defined risk groups.

The assumption is a simple one:

  • The risk that any man will be diagnosed with incurable prostate cancer at less than 30 years of age is vanishingly small.

That does not mean that it will never, ever occur. It simply means the risk is probably one man in America in any one year or lower.

So how can we categorize the male population over 30 into risk groups in a meaningful way? Well here is a first suggestion:

  • Those with a family history of potentially lethal prostate cancer, i.e., men with at least one first-degree relative — a father or brother — who has been diagnosed with or gone on to need treatment for evident, metastatic prostate cancer.
  • Those with a family history of intermediate- or high-risk prostate cancer, i.e., men with at least one first-degree relative who has been diagnosed with intermediate- or high-risk prostate cancer.
  • Those with a family history of low-risk prostate cancer, i.e., men with at least one first-degree relative who has been diagnosed with low-risk prostate cancer.
  • Those with an ethnic risk for prostate cancer, which in America means predominantly men of African-American, Afro-Caribbean, and West African ethnicity
  • Those with an environmental risk for prostate cancer, which is currently not well defined but certainly seems to include men exposed to Agent Orange, men who have been significantly exposed to cadmium, and possibly some other environmental factors
  • Men over the age of 55, when the risk for age-related development of prostate cancer starts to rise significantly
  • Men over the age of 70, when the risk for age-related prostate cancer is high, but the risk of prostate cancer-specific mortality starts to fall because of overall life expectancy

One would think it might be possible to use such risk groups to assign an overall risk level to categories of individuals. Just as an example, a 56-year-old, African American male who works in a metals recycling business and with a brother who has already progressed after first-line treatment for high-risk disease is clearly at greater risk for clinically significant prostate cancer than a 72-year-old Caucasian with no family history who spent the past 40 years working in an office in suburbia!

If we add other factors such as CAPRA scores, it should be possible to define the risk level of an individual with considerable accuracy.

The question then becomes, can we associate risk groups and risk levels with specific recommendations? Should we, perhaps, be recommending that:

  • Most men with a family history of high-risk prostate cancer and an ethnic risk for this disease should be getting a baseline PSA at (say) 40 years of age followed by regular PSA tests at least every 2 years.
  • Most men over 75 with no other known risk factor and a current PSA level of <1.5 ng/ml do not need further PSA testing unless they have a reasonable life expectancy of  at least 15 years.

We have been careful, in these potential “recommendations,” to avoid “absolutism” by inclusion of the words “most men” (as opposed to “all men”).

The fact is that there is no guidance for the assessment of risk for prostate cancer today that everyone can agree with. It doesn’t matter why we are faced with this situation (money, bias, politics, bigotry, you name it). What matters is what we are going to do to resolve this. We need to get real.

  • What should a good primary care physician tell his patient today about risk for prostate cancer (and risks from treatment of prostate cancer)?
  • What should a specialist in the treatment of prostate cancer tell his patient today before giving him a biopsy?
  • What should a good prostate cancer advocate tell other undiagnosed men about their risk?

This is the second most common cancer currently diagnosed in America … and we don’t know how to educate ourselves because we can’t get clarity on some of the most fundamental issues, so we have listed out below what we think are some actual absolute facts. Anyone have a problem with any of these?

  • Progressive prostate cancer is not something most men should have to try to live with (with or without hormone therapy), so we need to minimize the probability of its occurrence.
  • Localized prostate cancer is often (but not always) curable.
  • Neither the DRE nor the PSA test (alone or in combination) is diagnostic or prognostic for localized prostate cancer; we need a better test.
  • Clinically significant prostate cancer and indolent, organ-confined prostate cancer should be treated differently.
  • No doctor really knows, today, whether or not they need to treat a 55-year-old man with a life expectancy of 20 years, just diagnosed with 1/12 positive biopsy cores (of less than 25 percent), Gleason 6 disease, and a PSA of between 2 and 10 ng/ml.
  • Even if we knew that we should treat him, no one knows what “the best” form of treatment would be for such a patient.
  • Every form of treatment for prostate cancer comes with some degree of risk for significant side effects.
  • Practically applicable, category 1 evidence about the relative risks and outcomes of the different therapies for prostate cancer is non-existant.
  • There is clear evidence that outcomes after every form of treatment for prostate cancer are profoundly affected by the skill, experience, and focus/dedication of the treatment team.
  • Finasteride and dutasteride have significant impact on risk for prostate cancer (and the relatively minor side effects of these two drugs are reversible for those men who find them difficult to live with).

Do you think there are other absolute facts that we can add to this list?

10 Responses

  1. Yes, there is one.

    Death from prostate cancer is not a “common cause” as stated by the ACS, for one. At less than 3% of male deaths, as a minority cause of death at all ages, it is misleading to allow the continuous spin that prostate cancer is “the second leading cause of death in men” — ooops, sorry, we meant to say, “It is the second leading cause of cancer deaths in men.”

    Facts are facts. Prostate cancer is only just in the top ten causes of death and is a long way behind the two leading causes — heart failure and other cancers, which together accounted in 2006 (the latest available figures) for 577,403 deaths as compared with 28,372 from prostate cancer.

    Prostate men need enlightening, not frightening.

  2. In number two of the “absolute facts” list, what is meant by “curable?” It’s a term that seems to have different meanings in different contexts. Need to clarify?

    Overall this is a great article — let common sense prevail amid all the noise that’s lately being generated by emerging guidelines and critiques of past practices!


  3. Terry: I think you may be splitting hairs. Most people would agree that any cause of death that is “in the top ten” should be classified as “common.” However. it is most certainly the case that heart disease and lung cancer alone are much, much more common causes of males deaths than prostate cancer.

    Reed: In this context, “curable” is intended to mean “elimination of the possibility that prostate cancer might become a cause of significant illness through the eradication of prostate cancer cells in the body (by any means).”

  4. I’m never one to argue, but I wouldn’t have thought suicide and influenza/pneumonia would normally be described as common forms of death, but I’m always prepared to learn.

    Do you think accidental death should be regarded as a very common form of death (presumably at a rate of about 3 times that of prostate cancer it should be qualified)?

    Guide me O Sitemaster. I learn at your feet.

  5. O Yana One Kenobe! I think we can safely say that “accidental death” is a surprisingly common form of demise — especially if you are including everyone who manages to “accident” themselves and others into oblivion through use of the more mindless forms of vehicular homicide (driving under the influence; driving while half asleep; driving while gabbing on cell phone; driving without any consideration of what is happening around you; etc.). Similarly, influenza/pneumonia has been a common form of death for tens of thousands of years because these are common and associated forms of infection that are particularly difficult to handle for the elderly, the very young, and anyone with a supressed immune function.

    Actually, the highest risk to mortality most otherwise healthy people take on a daily basis is when we drive our car out of its parking spot into moving traffic. I have been trying to explain this to people for years, but for some reason they are under the illusion that they are at much greater risk when flying. It’s not true!

    And the fact that there are as many suicides as there are is a sad comment on our failure as a society to appreciate that for tens of thousands of people every year, life really does become “not worth living.”

  6. Mike and Terry,
    After accidental deaths we have warning labels. So many warning labels that the industry of warning labels can probably be considered a major contributor of global warming. When I bought a new pickup truck, I stopped counting those plastic yellow ones in the truck when I opened up the owners manual and saw over 30 before getting to chapter two called “Safety Precautions.” All of them made a pretty simple point ~ don’t be obviously stupid.

    Unfortunately, I had no prior warning before I was diagnosed with cancer. I didn’t even know what PSA or a DRE were and at the time I had no family history to warn me. It would have been nice to have had a warning label on my Pampers. Or better yet ~ on my parents since heredity is so prevalent in the disease.

    As much as this controversy aggravates me, I find solace in the fact that there is attention on the subject. As they say ~ bad publicity is still publicity. My hope is that one day we get enough attention on awareness and that every man is smart about how to approach it should they be diagnosed. That they make the correct decisions, and avoid unneeded side effects or death by prostate cancer.

    Mike when we spoke the other day, I mentioned that we need organizations to be consistent and keep it simple. When I read this post, and pretty much agreed with it, I have come to the realization that neither may be realistically possible. So then when the AUA, NCCN, ACS, and so many others issue new guidelines and recommendations on testing, shouldn’t they just come with warning labels?

  7. Mike:

    About the flying part you are correct. I read once that about 45,000 people die each year in car accidents. That is the equivalent of two fully loaded 747s going down each week for a whole year. If what I read was correct. I still don’t like flying.

  8. While the need for treatment may not be obvious for a “55-year-old man with a life expectancy of 20 years, just diagnosed with 1/12 positive biopsy cores (of less than 25 percent), Gleason 6 disease, and a PSA of between 2 and 10 ng/ml,” it seems highly likely that frequent (quarterly?) monitoring of that patient’s PSA (and DRE?) is going to improve that patient’s quality of life. Or is that over simplifying?

    I would like to think there are some risk reduction behaviors (diet and exercise) that have a reasonable probability of reducing prostate cancer risk. Perhaps those can be added to the things we agree on.

  9. Dear Dave:

    Perhaps what is most likely is that we could all agree that such a patient (if untreated) needs regular monitoring of some type (still to be well determined) to minimize his risk for disease progression, and that a healthy lifestyle would optimize his probability for long-term overall survival with a good quality of life. (“A heart-healthy diet is a prostate healthy diet.”)

    My entirely personal opinion is that we still don’t have good data to be able to state with certainty that exercise and diet modification necessarily impact prostate cancer-specific survival.

  10. I am 72 years of age and have been having routine PSA tests for over 3 years in France. I have never had any prostate symptoms but, nevertheless, my PSA level has continued to rise. In the first year, my GP seriously suggested that I consider having my prostate removed “to give me peace of mind” (no mention of possible side effects). I have been referred to a specialist three times, who insists that I should have a biopsy to enable him to recommend appropriate treatment. My GP has recently extrapolated from the PSA level alone that I have a 50:50 chance of developing aggressive prostate cancer. My own research suggested that for every 50 men treated for prostate cancer, only two of them actually benefited from the treatment. As I have a good quality of life with plenty of exercise and a good diet I am seriously considering having no more PSA tests. I would prefer to maintain my quality of life for as long as possible rather than subjecting myself to forms of treatment which will almost certainly result in impotence and incontinence.

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