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

Posted Mar 15 2010 12:00am

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?

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