Prostate cancer screening: Should you or shouldn’t you? – By Kristen Jordan Shamu (Detroit Free Press) / May 8 2018
To screen or not to screen for prostate cancer is a question that men aged 55 to 69 should decide themselves in consult with their doctors, according to finalized guidance from an influential panel of health care experts.
After urging doctors in 2012 not to routinely screen men for prostate cancer because the risk of false positives and treatments for the generally slow-growing cancer could do more harm than good, the U.S. Preventive Services Task Force changed its recommendation Tuesday in an article published in the Journal of the American Medical Association.
Now, the task force urges men ages 55 to 69 to talk to their doctors about the risks and advantages of screening before deciding whether to undergo periodic prostate-specific antigen-based testing. It upholds its recommendation that men ages 70 and older should not be screened.
Dr. Ken Kernen, a urological oncologist with the Michigan Institute of Urology said the task force’s updated guidelines more closely mirror the recommendations of the American Cancer Society and the American Urological Association, which suggest most men begin prostate cancer screening at age 50.
Screening beginning at age 45 is recommended for men with a family history of prostate cancer and for African-American men. Those at highest risk, with more than one close relative who had prostate cancer at an early age, should start screening at age 40, the American Cancer Society suggests.
Dr. Ken Kernen is a urological oncologist with the Michigan Institute of Urology. (Photo: Kristen Jordan Shamus, Detroit Free Press)
Screenings are not recommended for men ages 70 and older.
“I’m glad the task force has changed the recommendation,” Kernen said. “I think it’s more in line, and it’s going to help save men’s lives.”
Prostate cancer is the second-leading cause of cancer death in men. It often presents with no symptoms.
What complicates screening is that it usually grows so slowly, prostate cancer isn’t likely to cause harm. But there’s not a reliable way to tell which cancers are aggressive and more likely to metastasize or spread to other parts of the body.
The Free Press asked Dr. Kernen to explain what the change will mean for men:
QUESTION: Why have the guidelines changed?
ANSWER: In 2012, the task force basically came out and said, “Hey, no screening for any men.” When the task force originally came out (with the recommendation not to screen for prostate cancer), there were no urologists or medical oncologists on the task force.
Also, there has been what we call a stage migration because in the last few years, since 2012, we haven’t done a good job screening. There have been higher grade and stages of cancer diagnosed because we’ve missed the window on a lot of these men.
This is a disease that not many people talk about — men are embarrassed about it — so it’s a challenge to get it out there. Men just don’t talk about this disease a whole lot.
Q: What’s involved in a screening?
A: Basically, a screening test is a PSA (a blood test checking for prostate-specific antigen, a protein in the blood) and a prostate exam or a digital rectal exam once a year.
Prostate cancer (Photo: Moppet, Getty Images)
It’s probably the best screening test. Like any screening test, there can be some false positives. You know, an infection can raise your PSA, natural growth of the prostate over time can elevate the PSA. But if the PSA jumps suddenly or changes suddenly, that’s very concerning for prostate cancer.
Q: What does it mean for patients?
A: It’s good for men. You know, there are still roughly 26,000 men a year that will die from prostate cancer.
There’s a fair number of those men who didn’t get screened properly or didn’t get screened early enough, and so I think this is something to celebrate for men out there.
They need to be screened for prostate cancer. Nobody should die of prostate cancer. Yes, there have been some false positives. Yes, there has been some over treatment. But our goal, really, now is to customize cancer care for men with regard to prostate cancer.
Meaning, everybody should be screened appropriately. We shouldn’t miss any high-grade prostate cancers. You know, if we diagnose men with low-grade prostate cancer, they may not need treatment anymore.
The U.S. Preventive Services Task Force says if you don’t have a family history and are not African American, it’s screenings from 55 to 69 years old. The American Urology Association, the American Cancer Society, a few other urology groups suggest that at least starting at age 50 you should get screened.
Q: How do doctors sort through the varying recommendations?
A: Well, it’s interesting. A lot of the primary care doctors and a lot of the family medicine practice programs really don’t believe in prostate cancer screening because it comes down to an educational component.
In the urology world, we basically believe that no man should die of prostate cancer. If you essentially have a 10-year life expectancy and are relatively healthy, you should get screened for prostate cancer.
Q: Could you please speak to the notion of doing more harm than good with screenings for some men?
A: So, prostate cancer historically is a very slow-growing disease. So, if you are diagnosed hypothetically and you are 75 or 80, and you have a bunch of co-morbidities, you will likely die with prostate cancer, not from prostate cancer.
If you don’t have a 10-year life expectancy, you probably don’t need to worry about prostate cancer.
Where we saw harm done, I think, in the last six years, since 2012, is a lot of younger men were not screened and were not diagnosed, And there’s a percentage of those men who have high-grade disease and ultimately their life expectancy is changed dramatically because they got diagnosed with high-grade prostate cancer late.
I think everything we do in medicine and everything we do in life has risk-to-benefit ratios, right? I always joke with my patients and say you drove to my office, which we all know is the most dangerous way to travel. But you make these decisions based on risk-to-benefit ratios. There is risk in everything we do. Yes, a prostate biopsy has some risk of bleeding or infection, things like that, but these risks don’t compare to dying from prostate cancer.
Treatments for prostate cancer have some risk, though now with the customization of cancer care, we’re treating men who we know really need treatment. On men who have low-volume disease, we’re really not treating them. We’re just watching them on active surveillance protocols.
Plus, there’s been tremendous breakthroughs on prostate cancer surgeries. We do it all roboticly now so that decreases men’s risk of incontinence and sexual dysfunction.
It’s the same with radiation therapy and cryotherapy. The technology has improved dramatically, so again men’s risk of urinary incontinence and sexual side effects have really gone down.
We also have new genetic marker testing so … we can really tell what’s the risk of this disease progressing.
I would say in our practice right now, probably 25%-30% of our men with prostate cancer are on active surveillance, which is great. They don’t need treatment, and you’re following them along. You’re really preventing harm by the customization of cancer care, but you’re not missing those men who really need treatment, who otherwise would have metastasis and die.
Q: How do you determine whether someone has a 10-year life expectancy?
A: We look at overall state of health. Do they have a lot of co-morbidities? Do they have multiple diseases? There are insurance parameters you can look at, too. We have these life expectancy tables.
Q: What are the warning signs of prostate cancer?
A: We’ll have a man hypothetically at the age of 65 come in and his PSA is elevated. And he’ll say, “Well, I can’t have prostate cancer. I don’t have any symptoms. I don’t have any signs.”
I always tell people, the No. 1 sign and symptom of prostate cancer is you feel fine. It is not a disease until very late that you present with multiple side effects.
As we grow older, our prostates grow, so we have side effects of decreased force of stream, getting up at night to go to the bathroom, urgency, frequency. All of those are symptoms and signs of benign prostatic hyperplasia, which means the prostate getting larger as we get older.
People think those are symptoms of prostate cancer, but there are very few symptoms of prostate cancer until it’s very aggressive and has spread.That is why … screening appropriately is so critical for men.
Advanced prostate cancer symptoms, if it has spread to the bones, … are difficulty urinating, they have bone pain, blood in the urine. Those are some advanced symptoms.
Q: What do you mean when you say there is a strong family history of prostate cancer?
A: We’re looking for people who say, “My dad had prostate cancer, my brother had prostate cancer, and my uncles had prostate cancer.” We’ve a had some families where clearly it’s … rampant.
Now, If they tell me their dad got diagnosed at 95 with prostate cancer that’s different than within that 50- to 70-year range. That’s really what we’re looking for.
Q: What message do you most want men to know about this?
A: With every man I diagnose with prostate cancer, I tell them all, I will come to your work. I will come to your church. I will come to the breakfast place you go to with the fellas. I will talk to anybody who will listen about prostate cancer because men don’t talk about prostate cancer. It’s almost like its the scarlet letter.
They’re embarrassed about it.
I think women have done such a better job talking about breast cancer. I think everyone knows when Breast Cancer Awareness month is. Everybody, even the NFL, wears pink, right? Nobody knows when Prostate Cancer Awareness month is. Nobody talks about it. Part of that responsibility falls on the men themselves for not bringing it up and being embarrassed about it.
The task force recommendations are really important, but if men never show up, and never talk about prostate cancer, that’s really the big problem.
If there’s one thing I can stress, it is don’t be afraid. You shouldn’t die of prostate cancer. In today’s world, we’re going to treat you appropriately, screen you appropriately. You should never die of prostate cancer, but you don’t need to be embarrassed about it.
