Saturday, March 13, 2010

Prostate Cancer: Screening, Treatment Worse Than Disease?

The American Cancer Society (ACS) has just released its latest guidelines on prostate cancer screening. The changes in these guidelines are driven in part by the findings of two major studies, on either side of the Atlantic, whose results seem to question the benefits of early screening.  There is much debate from different health authorities on these guidelines and its changes - some of these discussions can be found in the LA Times, CBS News, or WebMD.
image by Phillie Casablanca 

The main issue focuses on the need for early screening, and the age at which such screening should occur. The original guidelines called for, among other things, general screening for all men starting at age 50. The revised guidelines suggest that men should start discussing the need for screening with their doctor at age 50, although those men at high risk for prostate cancer should start he process earlier.

Several issues conflict in this matter. On the one hand, early screening normally benefits patients, as cancers caught early are more treatable. But the actual test which is recommended by the ACS, PSA screening, may suffer from sever weaknesses, as discussed by the actual discoverer of PSA (prostate specific antigen), Richard Ablin, in an Op-Ed at the New York Times.

The problems with the test are compounded by the fact that prostate cancer generally (although not always) evolves very slowly. Aggressive treatment often comes with nefarious consequences for the patient, including impotence and incontinence. It is not always recommended, simply because you might sometimes die of old age before the cancer kills you. In fact, according to WebMD, prostate cancer is diagnosed in an estimated 80% of men at age 80, although it clearly will not kill most of them. As a result, a significant number of experts, including Dr. Ablin himself, argue against early screening for the general population.

The risk, however, is that, by delaying screening, you may miss the small number of prostate cancers that evolve quickly and may kill the patients. There is, unfortunately, no test that specifically targets these fast evolving cancers.

If you get tested and have a positive result, the treatment that you may receive is also subject to great uncertainty. In fact, a recent study (discussed here and here) and states that the treatment you receive largely depends upon which specialists you will see. Statistically you are more likely to get surgery if you see a urologist only, and radiation therapy if you see a radiation oncologist. To the man with a hammer everything looks like a nail...

Should you get screened? This is a topic of discussion between you and your doctor. But - for sure - do it while fully informed. And - if the test should come out positive - be careful to weigh all pros and cons before engaging into an aggressive treatment - or any treatment. For prostate cancer screening and treatment, it seems that the best approach is to educate the patient first.

Some more reading: the NYT editorial by Richard Ablin is  a must-read, and the Harvard  Medical School just came out with its 2010 report on prostate diseases (unfortunately needs to be purchased).

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