Prosate Exams

From Twin Cities.com (March 3rd, 2010)
Edited and abridged for use here

The American Cancer Society recently emphasized that annual prostate testing can lead to unnecessary biopsies and treatments that do more harm than good.

The cancer society has not recommended routine screening for most men since the mid-1990s, and that does not change. But its new advice extends farther to warn of the limitations of the PSA (prostate specific antigen) blood test that millions of American men get now. It also says digital rectal exams should be an option rather than part of a standard screening.

The new advice is the latest push-back from routine screening to hunt for early cancers. Last year, a government task force said most women don't need mammograms in their 40s and a physician group said most women in their 20s don not need annual Pap smears.
American men have long been urged to have prostate cancer screenings, but over time studies have suggested that most cancers found are so slow-growing that most men could have avoided treatment.

The cancer society is perhaps the most influential group in giving screening advice. Its new guidance released March 3rd on prostate cancer urges doctors to:

Discuss the pros and cons of testing with their patients, including giving them written information or videos that discuss the likelihood of false test results and the side effects of treatment.
Stop giving the rectal exam as a standard prostate cancer screening because it has not clearly shown a benefit, though it can remain an option.
Use past PSA readings to determine how often follow-up tests are needed and to guide conversations about treatment.

Prostate cancer is the most common non-skin cancer in American men. An estimated 192,000 new cases and 27,000 deaths from it occurred last year in the United States. It is a slow-growing cancer in many cases, and depending on a man's age, he may be more likely to die of something else. Major studies have suggested routine screening does not save lives and often leads to worry and unnecessary treatment.

The new cancer society recommendations could change how routine physical exams for many older men are conducted. About 41 percent of men 50 and older get annual prostate cancer screenings. Even though the cancer society doesn't recommend routine PSA tests, many doctors do it without even asking their patients. And there's little conversation about it unless the test gives a worrisome result. The new guidelines may spur doctors to talk to their patients earlier about the pros and cons of getting the test in the first place. The guideline was also explicitly crafted to put a damper on community prostate screening activities that do not offer men the opportunity to make an informed decision whether to screen," Wolf said.

Concerns about the value of routine screening increased last year, after two large studies concluded screening for prostate cancer doesn't necessarily save lives, and noted any benefits can come at a high price.

The American Urological Association — a longtime proponent of regular screening — last year backed off its call for annual tests after age 50. The group said men should be offered a baseline PSA test at age 40, with follow-ups at intervals based on each man's situation. The group also has stood by the rectal exam as a standard part of screening, saying it can find cancer that the blood test does not.

The cancer society says some evidence indicates periodic screening can save lives but that there are significant uncertainties about the overall value of finding prostate cancer early. Screening should not take place, the new advice says, unless a patient is fully informed of the trade-offs.

Men at average risk should get detailed information around age 50, the society recommends. Men at higher risk, including African-Americans and men with a father or brother who had prostate cancer before age 65, should get the information beginning at age 45. Men with more than one close relative with prostate cancer before 65 should get such information at age 40.

For men who want to be screened regularly, the new guidelines recommend every other year if the PSA reading is less than 2.5, a measure of prostate specific antigen per milligram of blood. Annual tests are recommended for 2.5 or higher and a 4 suggests consideration of a biopsy.

The urological association considers the cancer society's advice too simplistic and says it's important to consider any rapid rise in PSA results.

The society's new guidelines rankled Skip Lockwood, president and CEO of Zero — The Project to End Prostate Cancer, formerly known as the National Prostate Cancer Coalition.

Lockwood's group recommends annual PSA tests for men beginning at 45, and conducts mobile prostate cancer screening programs at state fairs, churches and other sites. The group provides information about the risks and benefits of screening, and connects men to follow-up care if needed, he said.

What bothers him most in the new guidance is "the certainty of its tone," Lockwood said.
"We acknowledge that the PSA test is lacking. I think nobody disagrees on that fact. I think that we all understand that this is not cut and dry — not an all or nothing situation," he said.