Prostate Cancer Screening – What’s a Man to Do?

by Dr Nick

New Prostate Screening Recommendations

Cancer
Prostate Cancer Screening Guidelines

There’s a lot of talk in the news and spanning many of the social media networks with titles like this

Prostate cancer screening recommendations get rolled back by US task force

So what’s a man to do? Are we now all supposed to be getting prostate screening tests and what does that actually mean

 

Prostate Cancer Screening

Let’s start with the screening – this should consist of taking the patient’s history. Why is that important – certain factors will increase your risk of developing prostate cancer and should be taken into account. This is followed by a digital rectal examination. For those of you in the right age range that this advice applies to – that’s men aged 55 to 69 you may remember the iconic scene from the movie “Fletch” from 1985 staring Chevy Chase where he receives this very examination… “Moon River”

Not to make light of the examination but much like colonoscopy, it’s an essential part of our diagnostic tools and better yet it’s simple and painless. This is followed by a blood test to measure the Prostate Specific Antigen or PSA. Elevated levels of this in the blood can sometimes indicate prostate problems but part of the reason for the confusion and changing guidelines is the lack of specificity of this test. In medicine, we talk about specificity and sensitivity of tests that is defined by the ratios of positives, negatives and false positives and false negatives. The short version is there is no clear cutoff point for what is normal vs abnormal for the PSA level in our blood. We also see a significant percentage of men who have a normal PSA test but in study follow up were found to have prostate cancer.

This paper from 2012 reviews the clinical utility of PSA in Prostate Cancer: A Review on the Clinical Utility of PSA in Cancer Prostate, which highlights the further complicating issue that men are also found to have elevated PSA levels but no prostate cancer and the link between identification of prostate cancer with treatment and positive outcome effectiveness remains blurred

There is further evidence for the confusion in this 2015 meta-analysis that demonstrated a high incidence of latent or asymptomatic prostate cancer found after death and increases with age of the patient somewhere between 20-30% for this age group 55 to 59

Cancer
Prevalence of Prostate Cancer by Age

As the authors of this study put it

“Proponents of prostate cancer screening need to be wary of the high risk of overdiagnosis”

New Prostate Screening Guidelines

So what’s the change in guidance – well the United States Preventive Services Task Force changed its recommendation on prostate cancer screening from a D, which means don’t do it, to a C which means you should discuss it with your doctor

I’d hardly describe this as Prostate cancer screening recommendations getting rolled back but rather the thoughtful analysis of new data – in this case a study published in 2012 showing reduced relative risk from offering screening by 30 percent and a large randomized controlled study published in 2014 updating an earlier study that showed offering men screening reduced their relative risk of dying of prostate cancer over 13 years by 21 percent.

But it’s important to understand the difference between relative and absolute risk – we as humans are very poor at assessing risk in general and relative an absolute risk just make this harder

As Aaron Carroll, the Incidental Economist, in his analysis of the topic gave a clear explanation of the absolute versus relative risks tied to this data:

According to these studies, a 55-year-old man has about a 0.6 percent chance of dying of prostate cancer over the next 10 to 15 years. If he is screened, that chance goes down to 0.5 percent. That’s how you get almost a 20 percent relative reduction, but an absolute reduction of only 0.1 percentage points.

So out of 1,000 men screened, 80 will eventually have surgery or radiation. Three will avoid the spread of cancer to other organs. One or two will avoid death from prostate cancer. Sixty will have urinary incontinence and/or impotence. Many men will probably still think the risks outweigh the benefits.

The other important point here is that this change only applies to me aged 55-69. For those over the age of 70 the advice remains a D – avoid this screening.

So what should you do? Taking the advice of the task force and talk to your physician to discuss your personal circumstance and risk profile and understand the potential consequences of testing your PSA that proves positive and the path you then have to walk as a result of this result.

Incremental Steps to Men’s Prostate Health

  1. Assess Your Own Personal Risk of Prostate Cancer
    Educate Yourself on Prostate Cancer Testing and Treatments
    Understand Absolute versus Relative Risk
    If You Fall Into the 55-69 Age Group see your Physician and Discuss your personal risk profile
    If you are Over70 – Stay Educated but Don’t Get Tested
Cancer
Prostate Cancer Screening

 


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