Prostate Cancer Screening My Two Bobs Worth (20 cents worth for those born after 1966)
The past two posts published on this site, discussed issues surrounding prostate cancer screening and treatment. Debate is still raging throughout the world with study results quoted and decisions made creating mayhem among patients, medical practitioners and supporting associations. It seemed timely for me to add my thoughts on these issues and offer my opinions for discussion to anyone interested.
In my mind I think the actual term of prostate cancer screening is misleading for Australians as it implies that the male population is under some national program to regulate screening for this cancer. Eg mammograms, breast screening etc. There is no national program, you will not receive a written invitation from the government.
Screening for prostate cancer as I see it applies to the use of the PSA blood test and DRE examination. Both of these procedures are available to all men at the invitation of the GP or the request of the patient to the GP and would be better termed prostate function testing.
For better or worse the PSA and DRE procedures are the only common simplest testing available to men at this time. The PSA test comes in for heavy criticism on many fronts but is still the initial test that rings the alarm bell. So until research is able to find an improved substitute for these tests we should continue to use and improve the tools we have.
There are many forms of prostate cancer and each mans cancer is different. Some low and medium risk prostate cancers (Gleason grade 6 or 7) may never cause any health issues while some will turn aggressive and will be terminal. When low and medium risk prostate cancer has been diagnosed we have no way of determining if the cancer will remain indolent or will become aggressive. Improved research needs to be done in this area to find a way to better define the cancer that has been diagnosed.
Initial primary treatment for prostate cancer includes surgery, radiation, ADT drugs and/or a combination of these. Primary treatment can save your life or help manage the illness for those with aggressive prostate cancer. The price of this treatment can include either temporary or permanent side effects with urinary and bowel issues, including incontinence, erectile dysfunction, fatigue and a whole range of effects from the ADT treatment.
The considerable side effects of primary treatment for prostate cancer and the difficulty in determining between the prostate cancer that will kill you and the one that won’t is at the heart of the conundrum. Many men with low to medium risk cancer will elect to be treated who may not have needed primary treatment in the first instance.
There is another option for men diagnosed with low or medium risk cancer and that is with active surveillance over a period of time. In this case the patient and doctor will continue to monitor the PSA levels, conduct a DRE with follow up biopsies if needed on a regular basis. Further action could then be taken if and when indicated by a change in monitored results.
There are conflicting study results available that state there is no mortality benefit in screening (testing) and other study results that state there is a mortality benefit of 20% with regular screening (testing). Regardless of the arguments from all sides, the fact remains that one Australian man will die every three hours from this disease! So with proper education and information every man should have the right to make his own decision regarding to get tested or not.
Memorial Sloan-Kettering Cancer Clinic operate a set of guidelines for prostate cancer screening that seems sensible to me and I re- produce it here as follows:
Our doctors recommend the following screening guidelines for men expected to live at least 10 years:
- Men aged 45 – 49 should have a baseline PSA test. If the PSA level is 3 ng / mL or higher, men should talk with their doctor about having a biopsy of the prostate. If the PSA level is between 1 and 3 ng / mL, men should see their doctor for another PSA test every 2 – 4 years. If the PSA level is less than 1 ng / mL, men should see their doctor for another PSA test at age 51 – 55.
- Men aged 50 – 59 should have their PSA level checked. If the PSA level is 3 ng / mL or higher, men should talk with their doctor about having a biopsy of the prostate. If the PSA level is between 1 and 3 ng / mL, men should see their doctor for another PSA test every 2 – 4 years. If the PSA level is less than 1 ng / mL, men should see their doctor for another PSA test at age 60.
- Men aged 60 – 70 should have their PSA checked. If the PSA level is 3 ng / mL or higher, men should talk with their doctor about having a biopsy of the prostate. If the PSA level is between 1 and 3 ng / mL, men should see their doctor for another PSA test every 2 – 4 years. If the PSA level is less than 1 ng / mL, no further screening is recommended.
- Men aged 71 – 75 should talk with their doctor about whether to have a PSA test. The decision whether to have a PSA test should be based on past PSA levels and health of the man.
- Prostate cancer screening is not recommended for men aged 76 or older.
A high PSA level does not generally mean that a man should have a prostate biopsy. A doctor will often repeat the PSA test after a few months to determine if it is still high and investigate whether there is a reason other than cancer that could explain why the PSA level is elevated.
In summary it will still be an enigma for a man diagnosed with low-risk Gleason 6 or medium risk Gleason 7 to choose his path. Does he run the gauntlet of risking possible side effects and choose a primary treatment. Or does he accept to play mind games for a while and choose to sit on the fence with active surveillance. That is the Question????? However it should be each mans right to supply his own answer and provide his own actions.
Here endeth my post
Lee aka Popeye
Further reading and reference