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Doctors Differ on Prostate Screening

Helena Oliviero And Steve Visser New York Times Syndicate

06-06-13

ATLANTA -- Prostate screening tests detect prostate cancer early, but questions about whether the tests do more harm than good have made them one of the most hotly debated areas of medicine.

Some doctors and researchers believe testing for PSA, which stands for prostate-specific antigen, leads to unnecessary, costly and even harmful medical procedures because so many early diagnoses are slow-growing cancers that don't require immediate treatment. But men typically demand care once they hear the "C" word.

Those on the other side say PSA screening remains a valuable tool for detecting cancer early and saving lives.

Last month, The American Urological Association reversed course and no longer recommends routine screening for men 40 to 54 years old, who face an average risk of getting prostate cancer. It said testing should be considered primarily for those 55 to 69. Even then, a PSA test should not be automatic. Men should talk to their doctors about the benefits and risks and "proceed based on their personal values and preferences," the association recommended.

The urology group's announcement followed the 2011 recommendation by the United States Preventive Services Task Force, arguing against routine screening in healthy men because it often leads to unnecessary biopsies and surgery as well as life-altering complications such as impotence and incontinence.

A problem with screening is that PSA levels can be high, indicating cancer, even when a man doesn't have it. Another issue is that if a biopsy detects cancer, it is often slow-growing and, as cancers go, relatively benign.

In other words, a PSA test was taking healthy men and turning them into cancer patients who underwent radiation therapy, surgery and other invasive procedures for something that would never cause death or even lead to any symptoms.

But even seemingly benign cancer can turn serious. And some men want to turn back any risk of cancer immediately.

Four years ago, Michael LeBlanc, 62, didn't even think about waiting to treat cancer detected in his prostate. Whether the cancer was slow-growing or more aggressive was a moot point, he said.

"Although it's slow growing, what says tomorrow it won't change?" said LeBlanc. "It's like calling 911 and you say there is a man who broke into the house but he looks like such a nice guy, I don't think he's going to hurt us right away. A home invasion in a home invasion. Cancer is cancer. You don't dilly dally with that."

LeBlanc underwent robotic surgery to remove his prostate. He said an analysis indicated the cancer "had consumed my prostate." Exercise, he said, helped him make a full recovery.

Dr. Otis Brawley, chief medical officer for The American Cancer Society, has long called for more caution with prostate cancer screening, speaking against mass screenings such as the ones offered by health companies at shopping malls.

Many patients, he said, don't fully realize the potential complications associated with PSA testing.

"My whole campaign has not been one that men should not be screened," he said. "Let the man know the pluses and minuses, and what we know about the disease and the screening of the disease and then let the man decide," Brawley said.

That decision, he said, should be based on weighing the benefits versus potential harm of screening. Research of men 55 to 69 suggests PSA screening may prevent one death from prostate cancer for every 1,000 men screened at two- to four-year intervals over a 10-year-period, according to The American Urological Association. At the same time, many men who get the screening will be harmed because of treatments that can lead to health complications. Even a biopsy poses a risk of infection, for example.

Doctors may recommend "active surveillance" for men with low-risk prostate cancer tumors, in which the tumor is regularly monitored rather than treated. But getting patients to watch and wait is a difficult.

"Part of it is a reaction to cancer. The 1970s Nixon War on Cancer and there's this concept that all cancer is bad," said Dr. Martin Sanda, chairman of the Department of Urology at Emory University School of Medicine and director of the Prostate Cancer Center in Emory's Winship Cancer Institute. "But now we are pushing the envelope. Many of these (cancers) can be watched."

Over a five- to 10-year period, about a third of men whose cancers are considered low risk turn worse and require treatment, according to Sanda.

Sanda said a patient's decision about whether to monitor the low-risk cancer or undergo treatment often depends on how the information is presented. The key, he said, is explaining that the biopsies not only detect aggressive cancers that need immediate treatment but also pick up cancers that are "quasi cancer" and safe to watch rather than treat immediately.

But not all doctors are entirely comfortable with the concept of simply waiting and watching.

"These so-called quasi cancers may not be a problem at all. And there's also the possibility these quasi cancers can spread," said Dr. Marc Harrigan, a primary care physician at Piedmont Hospital. "You've got to put yourself in the shoes of the patient: 'Do I want something inside of me?' I mean, how comfortable would I be as a patient knowing there is a cancer inside of me that can grow at any time?"

Harrigan said his patients are predominantly African-Americans who face a higher risk for prostate cancer. They tend to opt for screening before 50. But Harrigan reviews the pros and cons of testing for any patient 40 and up. And then he lets the patient decide whether to get the PSA test.

"Who am I to tell patients you really shouldn't be tested until 50?" said Harrigan.

Sanda remains an advocate of screening -- which includes not only the PSA blood test but also the digital rectal exam. He sees firsthand what can happen when prostate cancer is not caught in the early stages.

"I see patients every month who are in their late 40s and early 50s and their cancer is too far along and we can't do anything to treat them," he said.

Sanda is also studying a new, more sophisticated blood test that could change the way men are screened. Studies indicate the Prostate Health Index, or phi, is more precise than the PSA and better distinguishes an aggressive cancer from a low-risk cancer.

It's one of several tests being studied across the country with the same goal: to have more accurate information, prevent unnecessary biopsies and treatments and the anxiety that often accompanies them, while saving lives from a disease expected to kill almost 30,000 men this year alone.

Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society's estimates for prostate cancer in the United States for 2013 are:

-- About 238,590 new cases of prostate cancer will be diagnosed.

-- About 29,720 men will die of prostate cancer.

-- Prostate cancer can be a serious disease, but most men diagnosed with prostate cancer do not die from it. In fact, more than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today.

-- About 1 man in 6 will be diagnosed with prostate cancer during his lifetime.

-- Prostate cancer occurs mainly in older men. Nearly two thirds are diagnosed in men 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 67.

Helena Oliviero and Steve Visser write for The Atlanta Journal-Constitution. Email: holiviero@ajc.com, svisser@ajc.com.  

c.2013 Cox Newspapers

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