Posts Tagged ‘PSA screening’

The New Skinny On Prostate Cancer Screening With the PSA Test

April 11, 2017

Prostate cancer remains one of the most common cancers in men and is the second most common cause of death from cancer in men.  (Lung cancer is still leading the list)  The American Cancer Society projects more than 161,000 new cases this year in the U.S., with about 26,730 deaths each year.  Prostate cancer accounted for 4.4% of all cancer deaths in the United States last year.

The U.S. Preventive Services Task Force, an independent and influential panel of experts, published new guidelines in early April 2017 for screening for prostate cancer for the first time in five years.

The new recommendations: Men ages 55 to 69 should “make an individualized decision about prostate cancer screening with their clinician.” That’s updated from a blanket recommendation in 2012 for no routine screening at any age.

The task force also recommends that those men older than 70 shouldn’t undergo PSA screening.

Now doctors are saying that the older recommendation in 2012, i.e., not to screen for prostate cancer likely resulted in deaths that could have been avoided..

The PSA test is a simple blood test that determines levels of the prostate-specific antigen protein, and elevated PSA can be a sign of prostate cancer. But elevated PSA can also be caused by other conditions, like inflammation of the prostate or benign enlargement of the prostate gland.

The risk of potential harm of over-diagnosis has led to confusing recommendations for screening. Treatment for prostate cancer, including removal of the prostate and radiation, is associated with the side effects of incontinence and erectile dysfunction.

False positives can lead to unnecessary further testing or treatment, and many cases of prostate cancer are slow-moving and require watchful waiting rather than immediate treatment.  This means that the men with slow growing, non-aggressive cancer can be followed with a digital rectal exam, frequent PSA testing, and perhaps additional prostate biopsies.

So how useful is PSA screening? According to the New England Journal of Medicine, studies imply that 1 prostate cancer death is averted per 1,000 men screened several times each, and followed for 10 to 15 years.

On the flip side, the authors reported, data show about 35 over-diagnosed cases per 1,000 men screened.

Some groups are at higher risk for prostate cancer, including African-American men and those with a family history of the disease.

Bottom Line: It is my recommendation to my patients 55-69 they have a discussion with their physician and weigh the benefits vs. the harms of PSA testing.  With that discussion the men can make the best choice for themselves, together with their doctor.

Prostate Cancer prevention-Diet and Exercise

September 19, 2015

I am often asked what can patients do to prevent prostate cancer. Prostate cancer is the most common cancer in men, and is the second leading cause of death from all cancers in the U.S. following lunch cancer, which is the most deadly cancer in men. In fact, half of men in their 80s have prostate cancer. While this may sound scary, the good news is that prostate cancer is usually slow growing and if caught early on, can be treated and stopped.

The truth is that prostate cancer is regarded as one of the most curable cancers, if caught early.

Signs of prostate cancer

Let me start that from the onset, early prostate cancer may have NO signs and NO symptoms.

If prostate cancer is advanced or spread beyond the prostate gland the signs may include:

  • Trouble urinating
  • Decreased force in the stream of urine
  • Blood in your urine or semen
  • Pain in your lower back, hips or thighs
  • Discomfort in the pelvic area
  • Erectile dysfunction
  • Elevated prostate-specific antigen test (PSA)

You may assume your urinary symptoms are a sign of a bladder infection or a kidney problem, but get it checked out. This can be especially true for younger men. While most cases of prostate cancer occur in men over 50, if you have difficulty starting a urine stream, have weak flow or have to go frequently, especially at night, get it checked out. It may not always be prostate cancer but does require an evaluation by a urologist.

Trouble urinating might simply indicate that your prostate is enlarged due to benign or non-cancerous causes. Having an enlarged prostate is not a sign of prostate cancer nor does it increase your risk of getting it.

Annual prostate screenings

Prostate cancer screenings work, especially for men ages 50 to 69. In recent years the formal recommendation for prostate screenings has changed. The U.S. Preventative Task Force on Health now says annual prostate screenings are not advised across the board, and are rather an item to be discussed and decided between a patient and doctor on an individual basis. If you have a family history, it’s a good idea to get checked regularly.

During a prostate screening, the doctor will test your PSA level, which is a simple blood test which measures a protein produced by your prostate gland. The higher the number, the greater chance you might have prostate cancer. (You should know that not all elevated PSAs point to cancer — some are caused by infections and even an enlarged prostate gland can elevate the PSA test.) Then, a physical exam is completed.

Preventing prostate cancer

Some risk factors for prostate cancer can’t be prevented, such as genetics and race. If you have a relative such as father, uncle, brother, or cousin with prostate cancer, then your risk is higher for prostate cancer. Also, African-American men have a higher incidence of prostate cancer and need to be screened at an earlier age.

While one in six men are diagnosed with prostate cancer at some time in their lives, that number increases to one in three for African Americans. Also, if you have a first degree relative who had prostate cancer — a dad or brother — your risk is doubled or tripled.

There are things you can do to prevent prostate cancer and cancer in general. Did you know that exercising three hours a week has been shown to greatly reduce your cancer risk overall? Eating well has similar results.

Live a healthy lifestyle: eat well, watch your weight and exercise frequently. By adopting a healthy lifestyle, you’ll decrease your risk for prostate cancer and other cancers as well.

 

Bottom Line: Prostate cancer is a common medical condition. Leading a health lifestyle with frequent exercise and a good diet can decrease your risk of developing prostate cancer.

PSA Testing For Prostate Cancer-New Recommendations For 2015

February 16, 2015

In 2012 the United States Task Force released guidelines for PSA testing for prostate cancer that stated that no man should be tested for prostate cancer with a PSA test since there was far too many man who were over-diagnosed and who had treatment and complications from the treatment and that the cancer was so slow growing that few men would die of their prostate cancers.

Two physicians’ groups are now recommending informed decision-making when it comes to screening for prostate cancer. This is in line with American Cancer Society guidelines for early detection of prostate cancer.

The American Urological Association (AUA), the leading organization representing urologists, is recommending more moderate use of prostate cancer screening tests.

In its new guidelines, the AUA recommends that men ages 55 to 69 discuss the benefits and harms of prostate cancer screening with their doctors before deciding whether to be screened. It recommends against screening for men younger than 55 who are at average risk, as well as for men 70 and older.

The American College of Physicians (ACP) released a similar guidance statement in April 2013. The ACP says men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen (PSA) test with their doctor before undergoing screening for prostate cancer. The guideline says only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test.

These new recommendations are closer to those of the American Cancer Society and several other groups issued in recent years. The American Cancer Society recommends that men discuss the possible risks and benefits of prostate cancer screening with their doctor before deciding whether to be screened. The discussion about screening should take place starting at age 50 for men who are at average risk of prostate cancer and expect to live at least 10 more years. It should take place at age 40-45 for men who are at higher risk, this includes African-American men and men who have a father or brother diagnosed with prostate cancer.

The discussion with the doctor should include an explanation to men of the uncertainty of the PSA test, potential harms from the prostate biopsy and treatments such as surgery and radiation, and potential benefits of PSA screening. Use of this test should be a decision made by the individual patient in collaboration with his healthcare provider.

Some limitations of screening

Screening looks for disease in people who have no symptoms. The main goal of prostate cancer screening is to reduce deaths due to prostate cancer. But the studies showed that the number of men who avoided dying of prostate cancer because of screening after 10 to 14 years was very small.

And screening isn’t perfect. Sometimes screening misses cancer, and sometimes it finds something suspicious that turns out to be harmless. The PSA test often produces false-positive results. For example men with an enlarged prostate gland or men with an infection of the prostate gland can have an elevated PSA level. Also, there aren’t reliable tests yet to tell the difference between prostate cancer that’s going to grow so slowly it will never cause a man any problems, and dangerous or aggressive prostate cancer that will grow quickly. Treatments for prostate cancer can have urinary, bowel, and sexual side effects that may seriously affect a man’s quality of life.

Bottom Line: The PSA is not a perfect test. It is inexpensive and it is non-invasive. It is useful as a baseline test and can help a man decide if he should proceed to a biopsy or to have treatment for his cancer. A thorough discussion between the man and his doctor is the best recommendation that I can provide for all men who are concerned about prostate cancer.

10 Medical Tests You MAY Be Able To Do Without

May 15, 2014

For years I have been writing and speaking on wellness and taking good care of yourself using preventive healthcare measures. Now with greater understanding of risks and benefits of tests, I am informing you of some tests that you may want to reconsider.

1. Nuclear stress tests, and other imaging tests, after heart procedures
Many people who have had a hear bypass, stent or other heart procedure feel they’ve had a brush with death. So patients — and doctors — understandably want to be reassured through a nuclear stress test or other tests that their hearts are beating strong. But performing these tests every year or even every two years in patients without symptoms rarely results in any change in treatment. In fact, post bypass or stent nuclear stress tests, can lead to unnecessary invasive procedures and excess radiation exposure without helping the patient improve. Instead, patients and doctors should focus on what does make a difference in keeping the heart healty: managing weight, quitting smoking, controlling blood pressure and increasing exercise.
2. Yearly electrocardiogram or exercise stress test
A survey of nearly 1,200 people ages 40 to 60 without any symptoms had an EKG over the previous five years. The problem: Someone at low risk for heart disease is more likely to get a false-positive result than to find a true problem. This could lead to unnecessary heart catheterization and stents. Instead, have your blood pressure and cholesterol checked. And if you’re at risk for diabetes, have your blood glucose level checked as well.
3. PSA to screen for prostate cancer
Cancer is always scary, but the PSA test often finds slow-growing cancers that won’t kill men. As a result of the test, he says, men often have ultrasounds, repeat lab tests and even biopsies for a problem that isn’t there — an estimated 75 percent of tests that show high PSA levels turn out to have negative prostate biopsies. When men do have treatments such as surgery or radiation, 20 to 40 percent end up with impotence, incontinence or both.
The American Urological Association, which supports the use of PSA testing, says that it should be considered mainly for men ages 55 to 69. After age 70, men without any urinary symptoms probably do not need further PSA testing.

4. PET scan to diagnose Alzheimer’s disease
Until recently, the only way to accurately diagnose Alzheimer’s was during an autopsy. In the last few years, doctors have begun using PET scans with a radioactive dye to look for beta-amyloid protein that is found in the brains of people with the disease. Although this test has promising use for research, there are serious questions about whether it should be used on those who complain of a fuzzy memory. PET scans in older people consistently find the protein in 30 to 40 percent of people whose memories are just fine.

5. X-ray, CT scan or MRI for lower back pain
Unfortunately, back pain is incredibly common — 80 percent of people, myself included, will suffer from back pain some time in their lives. It can be both excruciating and debilitating. Naturally, people want to know what’s wrong. Here’s the catch: The best imaging machines in the world often can’t tell them. Many older people with no back pain can have terrible-looking scans.
Most back pain goes away in about a month and imaging tests tend to lead to expensive procedures that often don’t help recovery. However, if your legs feel weak or numb, you have a history of cancer or you have had a recent infection, see your doctor as soon as possible.
6. Yearly Pap tests
The yearly Pap smear is a common part of women’s health checklists, but it doesn’t need to be. Women at average risk only need them every three years, since cervical cancer generally takes 10 to 20 years to develop. If women have also had negative tests for the human papillomavirus (HPV), which is now known to cause the cancer, they only need a Pap test along with the HPV test every five years. And women older than 65 who have had several normal Pap tests in a row can stop having them altogether. Do note, however, that a yearly visit to an ob-gyn stays on the to-do list.
7. Bone density scan for women before age 65 and men before age 70
For the estimated 10 million people — mainly women —in the United States who have osteoporosis, bone-strengthening medications can lower the chances of breaking a bone. But many experts argue that for those ages 50 to 65 who have osteopenia — mild bone loss — testing and subsequent drug prescriptions may be a waste of time and money. Not only is the risk of fracture often quite low, medications such as Fosamax (alendronate) and Boniva (ibandronate) have been linked to throat or chest pain, difficulty swallowing, heartburn, muscle pain, bone loss in the jaw and thigh-bone fractures. And there’s scant evidence that people with osteopenia get much benefit from the drugs.
To help keep your bones strong, try walking and weight-bearing exercises. Get enough calcium and vitamin D in your diet. If you smoke, quit.
8. Follow-up ultrasounds for small ovarian cysts
Many women receive repeated ultrasounds to verify that ovarian cysts have not become cancerous, but current research says that these tests aren’t necessary. For one thing, premenopausal women have harmless ovarian cysts regularly. For another, about 20 percent of postmenopausal women also develop harmless cysts.
The likelihood of these small simple cysts ever becoming cancer is exceedingly low.
In postmenopausal women, only cysts larger than 1 centimeter in diameter need a follow-up ultrasound. For premenopausal women, who typically have benign cysts every month when they ovulate, cysts smaller than 3 centimeters aren’t even worth mentioning in the radiologist’s report, says Levine.

9. Colonoscopy after age 75
Most people should have screening for colon cancer at 50 and then every five to 10 years after that, if the first test is normal. By age 75 — if you’ve always had normal colonoscopies — you can stop taking this test altogether. That should be good news, because a colonoscopy can cause serious complications in older people.
Just the preparation for colonoscopy can be exceptionally harsh. Some patients become incontinent or experience weeks of pain, diarrhea and constipation. In worst cases, the procedure can perforate the colon. Despite such risks, recent studies have found that substantial numbers of people over 75, even over 85, are still getting screening colonoscopies.
To protect your colon, eat plenty of fruits, vegetables and whole grains for fiber. Cut down on fatty foods, red meat and processed meats. Lose weight if you’re overweight and exercise. Sound familiar? It should, because that’s the best advice for protecting the rest of your body — and mind — as well.
10. Yearly physical
There’s little evidence that having an annual checkup can keep you healthy. Many tests that doctors regularly perform — to diagnose anemia, liver disease or urinary tract infections, for example — don’t make sense unless there’s a reason to suspect a problem. A healthy 52-year-old does not need to see the doctor once a year.
Certainly, if you have an illness that needs treatment, you should see your physician. And do talk to your doctor about how often you need to have your blood pressure and cholesterol tested. For these other tests, ask your doctor if they really are necessary and is the screening worth the risk of the procedure and are the benefits greater than the risks.

Medical Tests That You Can Do Without

March 11, 2014

I just had my annual physical examination. I am without any symptoms; take a baby aspirin and a vitamin; have no co morbid conditions. I asked myself did I really need a chest x-ray when I am exposed to so much radiation during my work at the hospital or did I need an EKG with no symptoms and a negative family history? I found my answer in a recent AARP article about “10 Tests To Avoid”.

1. Nuclear stress tests, and other imaging tests, after heart procedures
If you have had heart bypass, stent or other heart procedure, you don’t need nuclear stress test or other tests that their hearts are beating strong and the results rarely change the plan of management. Instead, patients and doctors should focus on what does make a difference in keeping the heart healthy: managing weight, quitting smoking, controlling blood pressure and increasing exercise.

2. Yearly electrocardiogram or exercise stress test
Someone at low risk for heart disease could be 10 times more likely to get a false-positive result than to find a true problem with their heart. The stress test could lead to unnecessary heart catheterization and stents. Instead, it is important to have your blood pressure and cholesterol checked at least once a year. And if you’re at risk for diabetes, have your blood glucose level checked as well.

3. PSA to screen for prostate cancer
Cancer is always scary, but the PSA test often finds slow-growing cancers that won’t kill men. An estimated 75 percent of tests that show high PSA levels turn out to be false alarms.
The American Urological Association, of which I am a member, supports the use of PSA testing, but should be considered mainly for men ages 55 to 69. I also believe that no testing is required in the man without any symptoms if the man is more than 75 years of age. However, men with a positive family history of prostate cancer and African American men should have an annual PSA test and a digital rectal examination.

4. PET scan to diagnose Alzheimer’s disease
In the last few years, doctors have begun using PET scans with a radioactive dye to look for beta-amyloid protein that is found in the brains of people with the Alzheimer’s disease. Even if a PET scan could accurately diagnose the disease, it’s untreatable. If you’re concerned about your memory, the better course is to have a complete medical evaluation by a doctor who specializes in diagnosing and treating dementia.

5. X-ray, CT scan or MRI for lower back pain
Back pain is incredibly common — 80 percent of people will suffer from back pain some time in their lives. It can be both excruciating and debilitating. Naturally, people want to know what’s wrong. Here’s the catch: The best imaging machines in the world often can’t tell them. Many older people with no back pain can have terrible-looking scans.
Most back pain goes away in about a month and imaging tests tend to lead to expensive procedures that often don’t help or shorten recovery. If you don’t feel better in a month, talk to your doctor about other options such as physical therapy, yoga or massage. But if your legs feel weak or numb, you have a history of cancer or you have had a recent infection, see your doctor.

6. Yearly Pap tests
The yearly Pap smear is a common part of women’s health checklists, but it doesn’t need to be. Women at average risk only need them every three years, since cervical cancer generally takes 10 to 20 years to develop. If women have also had negative tests for the human papillomavirus (HPV), which is now known to cause the cancer, they only need a Pap test along with the HPV test every five years. And women older than 65 who have had several normal Pap tests in a row can stop having them altogether. Also, if you have had a total hysterectomy for a benign condition such as uterine fibroids and the entire uterus and cervix have been removed, you do not need any further Pap test. Do note, however, that a yearly visit to an ob-gyn stays on the to-do list.

7. Bone density scan for women before age 65 and men before age 70
For the estimated 10 million people — mainly women —in the United States who have osteoporosis, bone-strengthening medications can lower the chances of breaking a bone. But many experts argue that for those ages 50 to 65 who have osteopenia — mild bone loss — testing and subsequent drug prescriptions may be a waste of time and money. Not only is the risk of fracture often quite low, medications such as Fosamax (alendronate) and Boniva (ibandronate) have been linked to throat or chest pain, difficulty swallowing, heartburn, muscle pain, bone loss in the jaw and thigh-bone fractures. And there’s scant evidence that people with osteopenia get much benefit from the drugs.
To help keep your bones strong, try walking and weight-bearing exercises,. Get enough calcium, 1000mg\day, and vitamin D, 1000IU\day, in your diet. If you smoke, quit.

8. Follow-up ultrasounds for small ovarian cysts
Many women receive repeated ultrasounds to verify that ovarian cysts have not become cancerous, but current research says that these tests aren’t necessary. For one thing, premenopausal women have harmless ovarian cysts regularly. For another, about 20 percent of postmenopausal women also develop harmless cysts.
The likelihood of these small simple cysts ever becoming cancer is exceedingly low.

9. Colonoscopy after age 75
Most people should have screening for colon cancer at 50 and then every five to 10 years after that, if the first test is normal. By age 75 — if you’ve always had normal colonoscopies — you can stop taking this test altogether. That should be good news, because a colonoscopy can cause serious complications in older people.
To protect your colon, eat plenty of fruits, vegetables and whole grains for fiber. Cut down on fatty foods, red meat and processed meats. Lose weight if you’re overweight and exercise. Sound familiar? It should, because that’s the best advice for protecting the rest of your body — and mind — as well.

10. Yearly physical
There’s little evidence that having an annual checkup can keep you healthy. Now I they tell me! Many tests that doctors regularly perform — to diagnose anemia, liver disease or urinary tract infections, for example — don’t make sense unless there’s a reason to suspect a problem.
Certainly, if you have an illness that needs treatment, you should see your physician. And do talk to your doctor about how often you need to have your blood pressure and cholesterol tested.

Bottom Line: Use good judgment about your health and your visit to the doctor. Ask the doctor if the test is really necessary and if the results will change how he\she is taking care of you. My message is that patients, including myself, need to become involved in their healthcare.
This article was inspired and modified from AARP, 10 Test to Avoid, by Elizabeth Agnvall, http://www.aarp.org/health/conditions-treatments/info-2014/choosing-wisely-medical-tests-to-avoid.3.html

To PSA or not to PSA…that is the questio-Everything you wanted to know about PSA and not afraid to ask?

August 21, 2013

John Doe is 55 years old. He has no urinary symptoms. He goes for his annual physical exam. His prostate exam is normal, but his prostate specific antigen (PSA) blood test is 4.5, which is slightly elevated. His last PSA test was 2 years ago, and at that time it was 2.7. He is referred to a urologist and a discussion takes place regarding whether he should proceed to a prostate gland biopsy based upon this elevated PSA. What is he to do? This chapter will review the background of the PSA test. What is it’s purpose, and how it is used to make decisions regarding the diagnosis, evaluation and management of men with prostate issues and prostate cancer.

PSA is the most useful and accurate cancer marker of all the cancer “markers” used in medicine today. This statement is of almost universal agreement among physicians and researchers working in cancer treatment and research. Some of you may find that statement a bit startling in light of all the negative press that has appeared regarding the PSA test in recent history. Lets define then what is meant by a “marker.” This is different than cancer screening” which has actually been where the controversy surrounding PSA has arisen. A marker for a tumor is “A substance that can be detected in higher than normal amounts in the blood, urine, or body tissues of some patients with certain types of cancer.” (medterms.com) Other examples of tumor markers include CEA in the case of some gastrointestinal tumors, CA-125 as a marker in ovarian cancer, Beta-HCG and alpha-fetoprotein in some testicular tumors, and even abnormal cells found in a Pap smear used to detect cervical cancer in women.

But as markers go, the PSA test, in a patient diagnosed WITH prostate cancer (PCa), no marker is superior in monitoring the progress and even prognosis of a PCa patient as is the PSA test.

HISTORY OF PSA

It may seem as if we have always used the PSA test in screening for, and in evaluation and follow-up of men with prostate cancer, but its usefulness in this arena is actually of fairly recent onset. There is no question that the discovery of this tiny molecule has dramatically, and forever changed the playing field in the world of PCa.

Before the discovery of PSA the world of screening for, and of attempting to make an early and timely diagnosis of prostate cancer was entirely different. In the pre-PSA era, and this includes all the years prior to the late 1980’s and early 1990’s when PSA became clinically useful, it was very difficult for clinicians to diagnose PCa in a stage where it could be cured by the therapies of that time. Prior to the use of PSA as a screening tool, all we clinicians had at our disposal was our digital exam, our level of suspicion based upon a family history, and to some extent, a blood test called Prostatic Acid Phosphatase, or PAP. Unfortunately, in a large number of men eventually diagnosed by one of these methods, the cancer had often spread beyond the prostate, and hence, was incurable by the technologies of the time.

As strange as it may sound, the actual discovery of PSA is clouded in controversy, and it seems several scientists have been called the discoverers. PSA seems to have been first identified in he U.S., by Dr. Richard Ablin and his associates as early as 1970. A subsequent article by Dr. Ming Wang was published in 1979, and this has often has been cited, apparently incorrectly, as the first scientific article cited as the “discovery” of PSA. This 1979 publication however, was the first to advance the idea that the PSA test could purified and could be useful in detection of prostate cancer. At this point, research was then directed towards developing a commercially usable, reliable, reproducible, and reasonably priced blood test that could be made available to the public.

Some of the very early developmental research for PSA was on it’s presence in semen and to assess it’s properties and usefulness as a forensic marker for rape victims. Soon however, the usefulness of PSA as a screening tool for prostate cancer became quite evident, and as they say, “the rest is history.”

As early as 1981 research was demonstrating significant differences in the blood PSA levels in patients with benign, non-cancerous prostate enlargement (BPH) as opposed to men with prostate cancer. In addition, research in the early 1980’s was demonstrating that men with more advanced prostate cancers had higher blood levels of PSA than men with less advanced cancer.

So, as literally millions of data points were studied, what then is accepted as a “normal” PSA. The very simple answer is up to 4 nannograms per milliliter, or 4ng/ml. It’s never really that simple however. There are many nuances the physician must consider when evaluating a man and his PSA. For example a PSA of 3 in a man of 50 might be worrisome, where a PSA of 5 in a 75 year old man might not be. Change over time can be important. A man whose PSA went from 1 to 3 in one year, both “normal” numbers, might be more worrisome for cancer than a man who has had PSA’s between 5 and 7 over the past 10 years. More on this later, but for most lab reports you will see “normal” for PSA as between zero and 4.

During this same timeframe it was becoming apparent that men who had undergone curative treatment for prostate cancer had PSA levels close to zero, and that if the cancer reappeared, the PSA levels began to climb, making the test very useful in following, or monitoring patients to detect failure or success of treatment. In addition, it became clear that a rise in PSA could be seen usually long before the location of the recurrence could be detected by other means.

Despite all this favorable research data accumulating in the early 1980’s, PSA was originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who were diagnosed with the cancer. It may surprise you that it was not until 1994 that the FDA approved the PSA blood test , along with a digital rectal exam (DRE), to screen men without symptoms, for prostate cancer. Clearly, over this two decade period, screening for cancer with PSA and DRE has become commonplace in medicine.

Things have now gone backwards in the eyes of many clinicians, in that NOW, another governmental agency, the U.S. Preventive Task Force (USPSTF) recommends AGAINST prostate cancer screening. More on this controversial move, to follow.

Since PSA has dramatically changed our approach to screening for, diagnosing, and monitoring prostate cancer, what has changed in the two decades since this approach has been in full swing? The incidence rates for PCa took a significant upturn at the same time PSA test was approved by the FDA, and even before it was FDA-approved for screening of asymptomatic men. Clearly, clinicians recognized its utility for screening before it was “officially” approved for this particular use. The incidence rates of prostate cancer remain much higher than it was in the pre-PSA era. This is a reflection of our ability to diagnose the disease much earlier now, and not due to an actual increase in the true incidence of the disease in our society. One of the arguments of proponents of “non-screening” with PSA is that many more men are being diagnosed with cancer that might never have impacted their lives had it never been detected. More on this later.

Along with improved early detection brought on by the advent of PSA, the death rates have also begun to fall. This would certainly be anticipated. If we can diagnose cancer, or for that matter, almost any medical condition, before it is far advanced, our chances of cure or survival are enhanced. Death rates, calculated as rates per 100,000 males was rising slowly from about 1940 until about 1985 when the death rate took a spike through about 1995, and has fallen steadily over the past 20 years or so.

The number of men dying in the U.S. yearly from PCa is a little over 30,000. Many clinicians involved in studying this disease feel that if these men who die of the disease had been seeing a physician yearly, and had been undergoing appropriate screening we might be able to drop this number of deaths perhaps as much as 90%. Even with appropriate screening, and let’s say even if 100% of men over the age of 50, could be screened yearly for PCa, there would still be some deaths from the disease. Some men, albeit a small percentage, will develop a form of prostate cancer that is so aggressive and virulent, that even with the best treatments available to us today, we still cannot cure them.

Since it is intuitively clear to all of us, that early diagnosis of disease is good, and we all now know the wonderful utility of the PSA test in early detection of PCa, why has the test gotten so much negative publicity? In fact, if you have been watching, there has been almost no positive publicity in the past few years, but there has been an onslaught of negative. We physicians are asked daily now by our patients as to why there is this negativity, and then whether they should be doing the test. More about how to make the decision to test, or screen, for prostate cancer. Some guidelines to help you in this decision will follow in soon in this chapter.

We will look into the science, and some would call it “junk science” behind the recommendations of the U.S. Preventive Services Task Force recommendations against screening for prostate cancer, but let’s first take a look at some of the “politics” if you will, of cancer screening in general, as this puts a lot of it into a perspective we can all understand. A lot of this seems to be driven by finances on both a private, federal, and state level. Since a large portion of the costs of cancer screening is borne by governmental agencies, and most of the rest, by private insurance, the costs have to be taken into consideration. Now, for the thousands, or millions of Americans whose lives have been saved by early detection, and cure of their own bout with cancer, these cost issues seem quite secondary to them, and to their loved ones. They know cancer screening saves lives. They are living proof.

To actuaries looking from under their green eye shades at the numbers, screening for cancer, regardless of the lives saved, does not make good policy or financial sense. And, they would say arguably, the costs are not sustainable. We all know Medicare is going broke, despite the fact that any of us who have a job, and are receiving a paycheck, are paying not only for the private insurance we are using now, but also Medicare premiums are being taken out of every paycheck. So where does screening for cancer fit in this financial mileu?

Several cancers have taken a hit lately. Screening mammograms for early detection of breast cancer in women came under fire recently. Women rose up, and the government and insurance companies backed off. Screening for cervical cancer has come under fire, and the recommendation for screening for colon cancer, largely under the radar, has changed too. Will lives be lost? Will failure to detect early cost us in suffering and early demise of untold Americans? Of course. But in a dollars and cents world, screening for cancer is just too expensive. Let’s take a somewhat imaginary look at the numbers before we look at the USPSTF recommendations in detail.

Let us imagine a million men being screened annually for prostate cancer. Since the numbers used here are estimates, they are going to be off a little from what might be absolutely correct, but since the actual numbers are not obtainable, the numbers we use here at least give us a reasonably accurate framework. And this is done, only to try and put the costs of cancer screening into perspective.

So, back to our one million men being screening annually for PCa. Let’s suppose that this could be done for about $75.00 to include a doctor visit, the exam, and the blood test. Right away we have consumed 75 million dollars. Let’s say that of those million men, everything is normal for 800,000 of them-probably a reasonable estimate. We are through with them for this year. Now of the remaining men something in the exam, the blood test, or the medical history is concerning. The doctor has a concern that these men might have cancer. For those being screened by their primary provider, a consult with a urologist will be needed. Some of these men will be seeing a urologist for their yearly screening, but the others will have to be referred. Let’s say conservatively that of these 200,000 men, 50,000 will need a new and initial consultation with a urologist, and the cost could be around $100.00 for this initial consultation. $5,000,000 there. Some will go to immediate biopsy, but let’s say the doctors decide not to do a biopsy on half of the men, but simply to recheck them, and obtain another blood test in couple months. These would be the men for whom the urologist is not highly suspicious for cancer, but they still will need to be followed appropriately. Another couple million for the second visit and testing of blood for PSA. Now let’s suppose that out of the one million men being screened, only 1% are ultimately thought to need a biopsy. That would be 10,000 men times a conservative cost for biopsy of $1,000.00. Another $ 10,000,000 dollars for the biopsies. Now if 1 in 4 had a positive biopsy, probably 3 in 4 with cancer would need treatment. Millions and millions have been spent before treatment has even started.

So, using these numbers, which are reasonable, the screening costs for 1 million men is easily in the neighborhood of $100,000,000. Now, what if we are trying to screen 5 million men, or 10 million men, or more, yearly? You can see how this adds up to astronomical numbers. And this is only for one cancer. We have not even looked at screening for breast, colon and lung cancers which make up the rest of the “big four.”

With this financial meltdown facing health insurance providers one can see why screening for cancer has become such an issue, and perhaps these numbers factor into some of the decision making processes.

Let us now take a look at the Draft Recommendation Statement from the USPSTF. First, at this time, it is a draft. More will come. If you care to review it in detail, it is available at http://www.uspreventiveservicestaskforce.org/prostate/prostateart.htm.

However, the salient points will be reviewed for you here. Quoting, “The USPSTF makes recommendations about the effectiveness of specific clinical preventive services without related signs or symptoms.” Keeping in mind here, by the time a man has symptoms or signs of PCa, the cancer has spread beyond the prostate and is no longer curable.

Quoting: “Summary of Recommendation and Evidence. The U.S. Preventive Services Task force (USPSTF) recommends against prostate-specific-antigen(PSA)-based screening for prostate cancer. This is a grade D recommendation.”

What is a grade D recommendation? If you ever got a grade of D in school, you know it is not good! Specifically, the definition is: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits. Their “Suggestions for Practice” here regarding screening for prostate cancer with the D rating, “Discourage the use of this service.”

Quoting further from the draft document:

“Prostate cancer is the most commonly diagnosed nonskin cancer in men in the the United States, with a lifetime risk of diagnosis currently estimated at 15.9%. Most cases of prostate cancer have a good prognosis, but some are aggressive; the lifetime risk of dying from prostate cancer is 2.8%. Prostate cancer is rare before age 50 years and very few men die of prostate cancer before age 60 years. The majority of deaths due to prostate cancer occur after age 75 years.”

Let’s take a quick look at this 2.8% risk of dying from prostate cancer. About 238,590 new cases will be diagnosed in the U.S. in 2013, and about 29,720 men die of this cancer in 2013 according to the National Cancer Institute estimates. It would appear from these numbers that the risk of dying from prostate cancer easily exceeds 10%.

The draft document goes on further to elaborate on harms of detection and early intervention to include risks associated with biopsy itself, the adverse effects of treatments be they surgery or radiation or hormone deprivation. Another risk is “overdiagnosis.” This, the panel seems to believe, results in many men being treated for cancer that never would impact their lives. Now since urologists and oncologists treating prostate cancer make every effort not to overtreat the insignificant cancers, we have to wonder what exactly is meant by this? As they were quoted above, “some of these cancers are aggressive,” is there a way to know which type (aggressive vs. non-aggressive) without a diagnosis? Do we as physicians owe it to our patients to help them make decisions for treatment based upon the best evidence we can provide? In most cases, one would answer yes to that question.

There is no doubt this panel put a monumental amount of time and effort into this document, and the conclusions they came to were based upon the evidence they felt was significant. They reviewed at least three large trials regarding prostate cancer, one called the PLCO, another, from Europe. The ERSPC trial, and the preliminary results from the PIVOT trial.

The USPSTF estimates that for every 1,000 men ages 55 to 69 who are screened every one to four years for a ten year period that only a maximum of one death from prostate cancer would be avoided. Using our estimated numbers above, this means it would cost about $1,000,000.00 to save one life. If this is true. There are other ways to run these numbers, and you mathematicians can have a field day with them, but you can see again, screening for cancer is very costly. Now we as physicians don’t see 1,000 men at a time, we see individual men just like you, and together you and I have to try and make our best decisions for your individual health. More on that decision making process later on.

On May 21, 2012, the USPSTF released it’s Final Recommendations of PSA Screening, and the final document confirmed what was said in the draft.

Urologists are at the forefront of being tasked with diagnosing, and in most cases, treating men with prostate cancer. We work closely with our oncology colleagues in men with very advanced cancer. The American Urological Association (AUA) has spoken out against the USPSTF recommendations.

The AUA’s position is one of outrage regarding the USPSTF position and takes the position that the Task Force “is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease. We hold true to our current position s supported by the AUA’s Prostate Specific Antigen Best Practices Statement that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.”

(Further 2013 position to be presented in May-will be elaborated here)

So, how are we, as men, to make decisions regarding PSA screening as it fits into our own individual lifestyle, expectations, and plans for our own medical futures?

In simplest terms, if you and your physician feel that if you are screened for PCa it would help you make decisions about the direction you would want to take if you were in fact diagnosed with prostate cancer, then screening is probably a wise step to take.

Let’s keep in mind a few facts. It is clear that PSA screening does reduce mortality from prostate cancer compared to men who are not screened. It is also true that screening has led to a diagnosis of PCa in men in whom the disease might never had caused problems. Many of these men were nonetheless, treated, hence “overtreatment.” It is also true that we as clinicians have gotten much better at helping to cull out those insignificant cancers and counseling our patients accordingly. It is also true that biopsy does carry some risk, albeit small, of serious infection. A small number of men, in our experience, less than 1% will require extended antibiotic therapy after a biopsy, and a few may even end up spending a few days in the hospital for post-biopsy fever and infection. It is also true that some men who are treated for prostate cancer will suffer adverse effects including incontinence, erectile dysfunction and bladder dysfunction. It is also true, that nearly all men who may have these effects can be adequately treated for these adverse consequences.

So, who should be screened? A life expectancy of 10 years is often used as a guideline. Clearly we don’t know how long we will live at any given time, but a very healthy 75 year old man might benefit from screening far more than a 60 year old man who has had a heart attack, bypass surgery, diabetes, high blood pressure and obesity. Now that 60 year old might live to a ripe old age, and that “healthy” 75 year old might have that fatal heart attack tomorrow. Hence, the dilemma we all face-patients and physicians alike. But we try to be as practical here as we can. But if you as a male patient feel that you would want to be in a position to make decisions regarding prostate cancer treatment if you were to be diagnosed, then the decision to screen is likely in your best interest. Our advice is to have this discussion with your physician before screening for prostate cancer.

HOW CAN WE IMPROVE SCREENING FOR PROSTATE CANCER?

With regards to PSA screening, what is on the horizon, and what do we have now to further refine and tighten our accuracy of screening for PCa?

Now that so much progress has been made with DNA and in clarifying the human genome, it seems likely that in the not to distant future, genetic identification of those either at high risk, or that in fact WILL develop prostate cancer seems plausible. We are not there yet.

From the National Cancer Institute, here are some ways that scientists and researchers are looking to improve PSA screening.

Free versus total PSA: The lower the free PSA is a percentage of total PSA the more likelihood of finding cancer, and a very low free PSA may be associated with more aggressive cancer. We like to see a free PSA greater than 25% of total. For example, a man with a total PSA of 5, and a free PSA of 2.5 has a 50% ratio. His likelihood of PCa is low (not zero though) Whereas the man with a total PSA of 5, and a free of 0.4 has a ratio of 8%, and his risk for having PCa right now is high. This is useful test, but not perfect.

PSA density of the transitional zone: To gather this information requires ultrasound measurements of the prostate, and though perhaps more accurate than PSA alone, this approach has not been fully validated.

Age-specific PSA reference ranges: Unless a man is taking medication to shrink the prostate, dutasteride or finasteride, the prostate grows a little each year. Hence there are more prostate cells to produce PSA. As a result, a “normal” PSA in a man of 70 may be different that “normal” at age 50. This approach lacks general acceptance in the urological community however, since its use may delay a diagnosis of PCa.

PSA velocity and PSA doubling time: You will recall earlier in this chapter we discussed the man whose PSA went from 1 to 3, as being perhaps more worrisome than a man with a PSA between 5 and 7 while being followed for a decade. Quoting from the National Cancer Institute, “Some evidence suggests that the rate of increase in a man’s PSA level may be helpful in predicting whether he has prostate cancer.”

Pro-PSA: There is quite a lot of work being done looking at these different inactive precursors of PSA, and there is some evidence that pro-PSA may be a better predictor, and hence a better screening methodology than PSA as we are using it today. This is not yet ready for “primetime” yet.

PCa3: This test is readily available for clinical use today, and has a place in our screening toolbox. PCa3 is a chemical produced in the prostate gland. In order to do the test, the physician must put a little pressure on the prostate while doing the digital rectal exam. This pushes a little prostate fluid into the urethra. The patient is then asked to urinate, and the first ounce or so of urine will contain that prostate fluid. This sample is then sent to a specialized lab capable of doing the test. If PCa3 is present in this urine sample, depending upon the degree, the risk of prostate cancer can be further elucidated. The nee for a biopsy can be refined depending upon the result of the PCa3.

One other approach that is receiving increased incidence we will mention only briefly here since this chapter is about PSA, but is being looked at as a screening tool for prostate cancer. This is not a blood test, but an imaging study. Prostate MRI with a powerful 3 tesla MRI machine has shown usefulness in imaging cancer with considerable accuracy within the prostate gland itself.

DEFINITIVELY DIAGNOSING PROSTATE CANCER:

As the science of prostate cancer diagnosis stands today, biopsy remains the only definitive way to make the diagnosis. There are a couple caveats here-a man with a PSA over 100 probably does not need a biopsy. A man who has on X-Ray definitive evidence of cancer in his bones, and a high PSA many not need a biopsy. However, this chapter is about screening, and especially screening in the man with no symptoms. In that man, biopsy of the prostate remains the final diagnostic test. The use of PSA and the other modalities mentioned above serve mostly to help the physician and the patient decide as to whether proceeding on to biopsy is indicated. We are trying to refine screening so that we will be able to avoid biopsy in many men because, as a result of screening tests, we can reasonably believe our patient does NOT have prostate cancer.

As is clear to all of you now, having read these pages, PSA remains an extremely valuable tool in our cancer screening toolbox. How it can be useful in the case of each individual patient remains just that, individual. With the information we hope you have gained in this chapter, you will hopefully be in a better position to understand the usefulness as well as the limitations of PSA screening. Hopefully the decision making process will be clearer to you as you have discussions with your physician regarding PSA screening for prostate cancer. For many of you, it will be quite simple. If for example, you are a healthy man between 50 and 70 years of age, and you already know that whether you have PCa matters to you so that you can make proper decisions, doing the test is a slam-dunk. This would include a wide swath of men. For some, it will not be so simple, and many factors will have to be considered prior to screening. We hope this chapter has helped.

Let’s go back to our patient described at the beginning of the blog: He is 55 years old, having no urinary symptoms and is in for his physical. His prostate exam is normal, but his PSA is slightly elevated at 4.5. Last year he did not have an exam, but two years ago it was 2.7. He is referred to a urologist and a discussion takes place regarding whether he should proceed to prostate gland biopsy. What should he do? What would you want to do it this was your data? Hopefully, you now have some parameters to help you make the decision in your own individual situation.

PSA Testing -To Screen Or Not to Screen-What the Experts are Saying

May 12, 2013

Prostate cancer is the most common non-skin cancer in men with 250,000 new cases every year. The disease can be detected by screening with a PSA blood test and a digital rectal exam. Some men with prostate cancer will go on to treatment and are at risk for complications including impotence or erectile dysfunction and urinary incontinence or leaking urine.
The American Urologic Association has just released new guidelines for prostate cancer screening that I would like to share with you and hope that you can use this information to make a decision if prostate cancer screening is appropriate for you.

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups.

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk, i.e., those men who do not have a family member with prostate cancer or men of African American race. For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making between doctor and patient for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. The greatest benefit of screening appears to be in men ages 55 to 69 years.

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. Additionally, intervals for rescreening can be individualized by a baseline PSA level.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy.
Some men over age 70 years who are in excellent health may benefit from prostate cancer screening.

Bottom Line: I think not to screen men at all is probably not a good idea. However, in selected men, the decision not to screen is probably a good one. I do believe that men need to have a discussion with their doctors and decide on a case by case basis whether or not to screen for prostate cancer using the PSA test.

Screening For Prostate Cancer-New Guidelines and One Doctor’s Advice

May 10, 2013

Prostate cancer is the most commonly diagnosed non–skin cancer among U.S. men. It can be life-threatening, and many men have cancer without knowing it. For those reasons, doctors sometimes look for prostate cancer in healthy men (screen for cancer) by measuring blood levels of prostate-specific antigen (PSA), a protein secreted by the prostate gland. High PSA levels can be caused by cancer and may lead a doctor to take a sample of prostate tissue to see whether cancer is present (biopsy). Most prostate cancer grows very slowly, however, and many men with prostate cancer die of other causes. Neither PSA testing nor prostate biopsy tells doctors with certainty which cases of prostate cancer are threatening and which require treatment. As a result, many men with slow-growing cancer have biopsies and treatment after PSA testing that they would not have needed if doctors had never tested them.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good — spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death. In 2012, the U.S. Preventive Services Task Force, an influential government-appointed panel, advised against any routine use of the PSA test for prostate cancer in all men.

Since most urologists consider the Task Force’s guidelines and global ban on PSA testing far too stringent For that reason, a group of experts at the recent 2013 American Urologic Association’s annual meeting in San Diego recently recommended against annual testing and prostate biopsies at certain PSA levels, usually a level greater than 4.0ng\ml. It is possible that using the PSA test differently (for example, by testing less often) would still be useful but reduce the harms of unnecessary treatment such as urinary incontinence and erectile dysfunction that come from more frequent testing.

What are the new AUA recommendations? There are several ways of using the PSA test to help men make the diagnosis of prostate cancer while reducing the harms of testing. The first way is to stop screening after age 70 years because men older than 70 years tend to have higher PSA levels without having prostate cancer, or if they have cancer, it is usually the slow-growing variety and does not result in a cause of older men’s mortality. Another way to use the new guidelines included measuring PSA levels less frequently such as every two years in men whose levels are normal especially when the initial PSA levels are less than 1.0ng\ml. Finally, the doctor caring for older men might recommend that they have higher levels of PSA before recommending a biopsy and possible unnecessary treatment.

It is hoped that the new recommendations by the American Urologic Association will result in more personalized health management where discussions will take place between doctor and patient and where the risk of having prostate cancer and the age of the man are balanced against the value of screening.
The new AUA guidelines are more nuanced. The group does recommend against the PSA test for men under age 40 or for those aged 40 to 54 at average risk for prostate cancer.

The AUA says, however, that men aged 55 to 69 should talk to their doctors about the risks and benefits of PSA screening and make a decision based on their personal values and preferences.

Routine PSA screening is not recommended for men over age 70 or any man with less than a 10- to 15-year life expectancy.

The best evidence of benefit from PSA screening was among men aged 55 to 69 screened every two to four years. In this group, PSA testing was found to prevent one death a decade for every 1,000 men screened. The guidelines also said PSA screening could benefit men in other age groups who are at higher risk of prostate cancer due to factors such as race, i.e., African American men and men with family history of prostate cancer. These men should discuss their risk with a doctor and assess the benefits and potential harms of PSA testing.

Bottom Line: What do I recommend that you tell patients? I agree with the guidelines that men over age 70 probably do not need to be tested. Also men younger than age 50 do not need to be tested. The exception is African American men and men with a family history of prostate cancer. I would not test a man with multiple chronic conditions, which would decrease his life expectancy to less than 10 years. I would also suggest that men with very low PSA levels, i.e., less than 1.0ng\ml, be tested every two years.

Finally, the discussions between a patient and his doctor on the PSA test are extremely important. I suggest you ask the man if he gets a PSA test, would he submit to a prostate biopsy and if he has prostate cancer would he accept treatment for the condition? If the answer is no, then I would document this in the chart and not obtain the test.

Treatment of Prostate Cancer in Older Men-Warren Buffet’s Experience

May 15, 2012

No one knows the right answer for the management of prostate cancer in older men. I would like to share an article that appeared in a blog by my friend, Dr. Kevin Pho

A version of this column was published on April 24, 2012 in USA Today.

There has been a recent uptick of elderly men in my primary care clinic asking about prostate cancer, perhaps because they heard of Warren Buffett’s recent prostate cancer diagnosis and his proposed treatment.

Patients are wondering if they should also be screened. Other patients who already have been diagnosed are wondering if they should receive radiation treatment for their prostate cancer, as Buffett is planning to do. It is very important to remember that what’s right for Buffett may not be right for everyone else.

According to Buffett’s letter to shareholders, his prostate-specific antigen (PSA) had been “regularly checked for many years.” A sudden jump in his PSA level led to a prostate biopsy and cancer diagnosis. But should an 81-year-old man even be screened for prostate cancer?

The evidence says no. The U.S. Preventive Services Task Force, an independent panel of non-government clinicians providing data-based practice guidelines, recommends against prostate cancer screening for healthy men. Studies over the years, which have included participation of more than 300,000 men of various ages, have failed to show prostate cancer screening saves lives.

“If there is significant benefit, it should have been apparent by now, and it is not,” said Virginia Moyer, chair of the task force.

The guidelines of other organizations, which are not as stringent as those suggested by the task force, also question Buffett’s routine prostate cancer screening. For instance, the American Cancer Society and American Urological Association both recommend that doctors discuss the pros and cons of prostate cancer screening with men whose additional life expectancy exceeds 10 years. Even by that measure, screening Buffett — who can expect to live another eight years, based on actuarial data from the Social Security Administration — is questionable.

According to his letter, Buffett was diagnosed with Stage 1 prostate cancer, meaning the cancer had not spread beyond the prostate. The prognosis is generally excellent for this early-stage cancer, and for many men, just monitoring the cancer to ensure it doesn’t spread is proper. More aggressive treatments are available, including surgery and radiation therapy, which Buffett plans to undergo. The problem with these options is that the treatment may be worse than the disease.

The fact is, 75% of men over the age of 80 have cancer cells in their prostate, but in elderly men cancer grows so slowly that the men are much more likely to die of something else.

Moreover, for all men, prostate tests are not sophisticated enough to determine which of these cancers are dangerous and which are not. Without knowing, most men opt for treatment. But for every 1,000 men treated for prostate cancer, five will die of complications from surgery. Side effects of both SURGERY and radiation can include impotence, incontinence and frequent urination — all for a disease that, at Stage 1, has less than a 1% chance of causing death in the next 10 years.

The annual cost of PSA testing contributes $3 billion annually to health care spending, much of it paid for by Medicare and the Veterans Administration, without significant health benefits. In fact, Richard J. Ablin, the scientist who discovered PSA, calls its widespread use a “public health disaster.” Buffett’s high profile cancer coverage should have been an opportunity to educate the country that, for many, more conservative options would not only save them from harmful, unnecessary treatments, but also potentially reduce health costs.

Instead, some may view Buffett’s decision to screen for prostate cancer and aggressively treat it as the right thing to do. I’m not second-guessing the approach taken by Buffett and his medical team. And I also understand that some men would rather know their prostate cancer status and accept the risks of too much testing. but we should realize that Buffett’s prostate cancer path isn’t necessarily the right road for every man.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

PSA Screening For Prostate Cancer-New Guidelines

October 26, 2011

By now, you’ve probably heard that prostate-specific antigen (PSA) screening is no longer recommended for healthy men under age 75. This controversial draft recommendation was issued by the United States Preventive Services Task Force (USPSTF). Given previous recommendations from the medical community encouraging PSA screening, many men are confused. Following are answers to some questions you may have about this recommendation — and our advice on whether you should follow it.
Should You Have a PSA Screening Test? Here’s what Johns Hopkins recommends for patients:
By now, you’ve probably heard that prostate-specific antigen (PSA) screening is no longer recommended for healthy men under age 75. This controversial draft recommendation was issued by the United States Preventive Services Task Force (USPSTF). Given previous recommendations from the medical community encouraging PSA screening, many men are confused. Following are answers to some questions you may have about this recommendation — and our advice on whether you should follow it.
What is the USPSTF? The USPSTF is an independent group of 16 medical experts whose recommendations serve as guidelines for doctors throughout the country. In addition, the group’s recommendations ultimately impact what tests Medicare and private insurers will pay for.
Why did they make this recommendation? According to the USPSTF, the potential harms caused by prostate-specific antigen (PSA) screening of healthy men as a means of identifying prostate cancer far outweigh its potential to save lives. The group discourages the use of any screening test for which the benefits do not outweigh the harms to the target population.
What are the potential harms of PSA screening? An elevated PSA reading can lead to an unnecessary prostate biopsy. Although biopsies often reveal signs of cancer, depending on a man’s age, 30 to 50 percent will not be harmful — even if left untreated.
After a positive biopsy comes the decision about what to do. Most men choose radical prostatectomy, external-beam radiation therapy or brachytherapy. But each of these treatments has the potential to cause serious problems like erectile dysfunction, urinary incontinence or bowel damage. And men who choose active surveillance must live with the uncertainty of knowing that they have an untreated cancer that could start to progress at any time.
Why does the Task Force believe PSA screening does not save lives? The USPSTF evaluated data from five large randomized clinical trials of PSA testing, including the Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Trial, which reported no mortality benefit among 77,000 men who underwent PSA testing and were followed for 10 years.
Do these recommendations apply to all men? These recommendations apply to all men regardless of age, race or family history as long as they do not have symptoms of prostate cancer.
My advice. Many leading cancer and patient groups and doctors agree that there is harm with PSA screening and the treatment that follows diagnosis. But a more targeted screening approach focusing on those at greatest risk of developing prostate cancer, and active surveillance for those who don’t need immediate treatment, could shift the balance of benefit and harm toward benefit.
PSA screening is the best test available for the detection of cancer cells in the prostate. Rather than discontinuing use of the only test available to detect the disease early and treat it successfully, efforts should focus on reducing harm.
Bottom Line: Every man should discuss the benefits and risks of PSA screening with his physician. If you choose to be screened and the result is positive, you and your doctor should discuss whether any further intervention is appropriate or necessary.