To Screen or Not To Screen?
The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information.
In recent years there has been a significant amount of controversy over prostate cancer screening. The controversy surrounding early detection of prostate cancer has prompted many medical organizations to develop prostate cancer early detection guidelines. The benefits and risks of screening are still being studied to determine whether or not yearly screening will decrease a man’s chance of dying from this disease.
There are benefits and risks to screening, for example a small prostate cancer that would never become life threatening may be detected which could result in unnecessary treatment. On the other hand, a prostate screening could detect an aggressive prostate cancer at an early stage, as opposed to not screening and diagnosing it at a more advanced stage. The decision to screen is a personal one and should be made after a discussion with your physician.
Ongoing studies to validate and improve the PSA test are being conducted; however it may take several years for the results of these studies to be published. As new information from these studies becomes available it should be discussed with your physician. Currently, Medicare provides coverage for an annual PSA test for all men age 50 and older.
Screening for Prostate Cancer
Several medical organizations, such as the American Cancer Society and the American Urological Association, have issued prostate cancer early detection guidelines, which include two tests to screen men for prostate cancer. In the first, known as a digital rectal examination (DRE), a doctor inserts a gloved finger into the rectum to feel for lumps in the prostate. In the second, a blood test detects the amount of a protein called prostate-specific antigen (PSA) circulating in a man's blood. These tests complement each other and are usually done together.
Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. While an abnormal DRE and an elevated PSA level (greater than or equal to 4.0 ng/ml) may be indicators of prostate cancer, neither test alone or in combination can provide a definitive diagnosis of prostate cancer — for this, a biopsy of the prostate is required. For example, men who have a common, noncancerous condition called benign prostatic hyperplasia (BPH), which is sometimes referred to as an enlarged prostate, may also have elevated PSA levels.
If your PSA is markedly elevated, regardless of your age, then your doctor will probably recommend a biopsy to determine the cause of the elevation. A biopsy involves obtaining a tiny sample of tissue from the prostate, which can then be analyzed. Prostate cancer, BPH, prostatitis, and other conditions can be diagnosed with a biopsy.
If your PSA is mildly elevated and you are young, otherwise healthy, and don’t have much of a family history of prostate cancer, then your doctor will likely wait and recheck your PSA level. Many conditions such as prostatitis are more likely to be the cause of a high PSA in a young, healthy man. On follow-up PSA testing, the PSA level should return to normal if it was temporarily elevated due to prostatitis.
If your PSA is not elevated and your digital rectal exam is normal, your doctor will likely do nothing more at the time, but will want to see you again in a year for another PSA test and DRE. Sometimes, if your PSA level is not elevated, but it has increased quickly in recent years, your doctor may be more concerned and recommended a biopsy.
If your PSA is not elevated, but there is an abnormality on your DRE, then a biopsy will likely be considered as well.
The discussion about screening should take place at age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
This discussion should take place starting at age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).
This discussion should take place at age 40 for men at even higher risk (those with several first-degree relatives who had prostate cancer at an early age).
After this discussion, those men who want to be screened should be tested with the prostate specific antigen (PSA) blood test and the digital rectal exam (DRE).
If, after this discussion, a man is unable to decide if testing is right for him, the screening decision can be made by the health care provider, who should take into account the patient’s general health preferences and values.
It is important to note that what is a normal PSA for one man may not be a normal PSA for another. Your physician will monitor your PSA and look for trends or changes in the results.
Men who choose to be tested who have a PSA of less than 2.5 ng/ml, may only need to be retested every 2 years.
Screening should be done yearly for men whose PSA level is 2.5 ng/ml or higher.
Because prostate cancer grows slowly, those men without symptoms of prostate cancer who do not have a 10-year life expectancy may not be offered testing since they are not likely to benefit. Overall health status, and not age alone, is important when making decisions about screening.
Other medical organizations note that reliable studies have yet to show that early detection and treatment result in fewer deaths from prostate cancer. However, most experts agree that the introduction of early detection programs such as DRE and the PSA test have played a significant role over the past ten years in the increased number of prostate cancer patients being diagnosed at early stages. And a number of studies have shown that prostate cancers detected through screening are more often confined to the prostate gland, and thus more easily treated, than those detected by a DRE alone. Additionally, the recent decline in deaths from prostate cancer in the US may have been caused, in part, by the increase in early detection.
Only you can decide if prostate screening is right for you.