Changing recommendations for prostate cancer screening requires doctor-patient dialogue

By Michaela Gibson Morris/NEMS Daily Journal

Men and their doctors have something to talk about.
The recommendations for prostate cancer screening have shifted away from every guy, every year after 50.
In May, the American Urological Association recommended that men of average risk ages 55 to 69 who have no symptoms of prostate cancer discuss the benefits and risks of prostate cancer screening before moving ahead. Last year, the U.S. Preventive Services Task Force recommended against general population screening, unless patients choose screening after weighing the benefits and risks.
“The greatest benefit of screening appears to be in men ages 55 to 69,” the association guidelines state.
For every man screened in this age group, the association’s analysis suggests one cancer death will be prevented over a decade; for a lifetime, the numbers are likely greater.
Based on its review of the research, the association is recommending testing every two to four years for the men who opt in. The intervals should preserve the benefit of screening and reduce the risks of:
• Overdiagnosis – treating slow-growing cancers that would have never caused symptoms in a man’s lifetime;
• False positives – benign conditions that trigger positive results in screening tests.
Men who are at high risk of developing prostate cancer – African-American men and those with family history – should develop an individualized plan for screening after age 40, the association recommends.
Tupelo urologist Dr. Kris Whitehead sees the new guidelines as part of a national shift away from screening focused to catch every possible aggressive cancer toward one that minimizes costs and reduces unnecessary procedures.
“These are good general guidelines, but it will cause a few cases to be missed,” said Whitehead, who has seen three aggressive cases of prostate cancer in men under 53 already in 2013.
The best prescription for a balanced approach is well-informed patients working collaboratively with their doctors.
Balanced approach
The prostate gland – which makes a component of semen – is about the size of a walnut. Prostate cancer is highly treatable if it’s caught while still localized in the prostate gland. Right now, about 75 percent of prostate cancer is diagnosed in the early stage, Whitehead said.
Many forms of prostate cancer are so slow growing they will never cause symptoms during a man’s lifetime, but others are very aggressive.
“There’s a misperception that all prostate cancers act in a similar manner,” Whitehead said.
The best screening test currently available is the prostate antigen test or PSA for short. It’s usually combined with a physical exam.
The PSA test is sensitive – it picks up nearly all early stage prostate cancer – but not specific. Other prostate conditions can trigger high levels of PSA, and PSA, in rare cases, can be normal in men who have cancer. Urologists usually look closely at how PSA levels have changed over time in making recommendations for biopsy. The PSA can’t separate aggressive cancer from the slow-growing varieties.
“The emphasis needs to be on how do we act on the information we find,” Whitehead said. “If someone does have prostate cancer, they need to discuss all the options.”
All forms of treatment – hormone therapy, surgery and radiation carry the risk of impotence. Surgery and radiation can cause trouble with urinary incontinence. Radiation therapy, additionally, carries the risk of bowel problems. And there’s the small, but inherent risks that come with any kind of surgery and treatment.
For some men, the default setting has been get rid of the cancer no matter what. That means they risk the side effects of treatment with little gain if their cancer is one of the slow-growing varieties. But automatically switching to watchful waiting isn’t a balanced approach either, Whitehead said.
“There’s no one-size-fits-all approach,” Whitehead said.
The biopsy results are being mined not just for the presence of cancer, but more and more, urologists are looking for specific DNA markers that can help indicate how aggressive the cancer is.
“We want to divide patients into low and high risk,” Whitehead said.
Personally, Whitehead feels very comfortable with the screening.
“I’m going to be screened for cancers and then make an informed decision if cancer develops,” he said.
michaela.morris@journalinc.com

Guidelines

AMERICAN UROLOGICAL ASSOCIATION updated its prostate cancer screening guidelines in May after a systematic review and analysis of published research.
• PSA screening in men under age 40 is not recommended.

• Routine screening in men ages 40 to 54 at average risk is not recommended.

• For men ages 55-69, the association recommends shared patient-doctor decision-making after weighing benefits and risks.

• For men of average risk who choose screening, the association recommends the screening on two- to four-year intervals.

• For men who have higher risk, such as African-Americans and those with a family history of prostate cancer, screening should be individualized after age 40.

Note: The screening recommendations apply only to men without any symptoms of prostate problems. Symptoms such as slow or weak urine stream, change in frequency of urination, blood in the urine or impotence should be evaluated. They can be related to a number of common, benign conditions, as well as cancer.