The American Cancer Society has revised its recommendations regarding prostate cancer screening. The new guidelines call for the patient to make an informed decision on whether to proceed with treatment. This comes just a few months after experts recommended against regular mammograms for women.
According to the ACS, “men with no symptoms of prostate cancer who are in relatively good health and can expect to live at least 10 more years have the opportunity to make an informed decision with their doctor about screening after learning about the uncertainties, risks, and potential benefits associated with prostate cancer screening. These talks should start at age 50. Men with no symptoms who are not expected to live more than 10 years (because of age or poor health) should not be offered prostate cancer screening. For them, the risks likely outweigh the benefits, researchers have concluded.”
As for higher risk patients, including African-Americans and men with family history, ACS recommends beginning those “conversations” at age 40 or 45, depending on risk. According to the ACS, “for men who choose to be screened after discussing the pros and cons with their doctor, the new guidelines make the digital rectal exam (DRE) optional and offer the option of extending the time between screening for men with low PSA levels.” For those unable to decide, the ACS says the doctor should make the call. Read the full report in CA: A Cancer Journal for Physicians.
In related news, The New York Times reports on a new drug designed to benefit men with advanced prostate cancer. “Men whose cancer has spread beyond the prostate gland are usually treated with drugs that reduce the body’s production of testosterone…. When such therapy fails, the only approved option now is the chemotherapy drug Taxotere, but that often fails as well….The new chemotherapy drug, cabazitaxel, would step in when Taxotere stops working….In the clinical trial, men who received cabazitaxel lived a median of 15.1 months, compared with 12.7 months for those who received another cancer drug, mitoxantrone, a difference that was statistically significant.”
First off, prostate cancer is a terrible disease and I commend urologists in their fight and plight against this scourge. That said, the PSA test is not a specific test, it is not a sensitive test. Screening tests are generally given to populations that are mainly without disease, so when there is an error it often falls in the majority group, ie the people without disease, i.e. a false positive result. If there is a positive finding the follow-up test, prostate biopsy is both expensive and poses a not insignificant risk to the patient. If the result was not a false positive their is then no good way to stratify which are the very slow growing prostate cancers which might be addressed with “watchful waiting” versus the more malignant and aggressive types. Finally if one chooses to intervene there is no home run treatment in fact its hard to say whether the treatments are often really of much benefit at all in terms of over all mortality while they carry a significant risk of long term complications. Evidently, two recent studies have now also supported that PSA screening is not of benefit and may actually be harming patients from the unnecessary procedures secondary to false positives.
So likely the PSA test isn’t worth it, which then brings up a related question which may sound flippant but I think is entirely reasonable. Unless you have Dr. Goldfinger, the dreaded finger wave is a worse test than even PSA as a screening test. Is their any rationale reason for a digital rectal exam as a routine urologic screening?