An Apple A Day

"An Apple A Day"

Orcas Family
Health Center
A Washington State and IRS 501 (c) (3) charitable non -profit corporation

"Apple A Day Articles"

ADULT “CHECK-UPS”

AN APPLE A DAY...FOR WOMEN

COMMUNICATION BASICS

FDA LICENSES NEWVACCINE FOR PREVENTION OF CERVICAL CANCER

GETTING THERE FROM HERE

LEMONS AND LYMES

NO MERCY FROM MRSA

ONE FLU OVER THE CUCKOO'S NEST

PROSTATE CANCER SCREENING

TO ERR IS HUMAN

PROSTATE CANCER SCREENING

This is clearly a tough one. For the past several months we have presented a series of articles covering adult screening tests as recommended by the United States Preventive Services Task Force (USPSTF). Previously we have presented the concept and criteria of screening tests, those tests recommended for both men and women as well as those exclusively for women. Today we present the final article in our series, the single screening test that is solely for men, that for prostate cancer.

Prostate cancer is second only to lung cancer as a cause of death in men. Each year about 180,000 men are diagnosed with prostate cancer and around 30,000 die from it. The risk of getting prostate cancer increases with age. The difficulty comes in knowing that older men who do get prostate cancer tend to have a relatively benign form of the disease not likely to cause death. Often quoted is the adage "older men die with prostate cancer, not because of it". Younger men may have a more aggressive form of prostate cancer. Statistically, however, in either age group there is no evidence that mortality is altered with treatment of prostate cancer versus non-treatment.

The medical and lay literature is full of articles portraying the significant controversy over how and even whether to screen men for prostate cancer. Potential tests include a digital rectal exam (DRE), a blood test for prostate specific antigen (PSA) and rectal ultrasound. The USPSTF gives screening for prostate cancer an "/" recommendation (/=Evidence is insufficient to recommend for or against the test) with the comment there is "good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence

that early detection improves health outcomes. Screening is associated with important harms.....evidence is insufficient to determine whether the benefits outweigh the harms for a screened population."

For the purpose of discussion, let us assume a patient has chosen to have prostate cancer screening with a PSA test. A normal value is generally considered to be less than 4. However, up to 25% of men with a "normal" PSA actually are later found to have prostate cancer (a false negative result). Likewise, an elevated PSA does not mean prostate cancer over 70% of the time (a false positive result). Now what? Further, let us assume our hypothetical patient has an elevated PSA and chooses to take the next step by undergoing a biopsy of his prostate and cancer is found. Now what? There are four treatment options- surgery to remove the prostate, radiation (either external or implanting radioactive seeds in the prostate), hormone therapy or do nothing, watchful waiting. Remember, the mortality from prostate cancer is identical between those that opt for treatment of any kind and those that do nothing. With all this uncertainty it is extremely difficult to counsel patients when and whether to have a prostate cancer screening test done and what type of treatment to recommend with an abnormal result. To further muddy the decision waters, it is important to know that treatment, especially surgery, has the potential for significant complications such as urinary incontinence and erectile dysfunction.

Our experience has been there is a lot of emotion and strong opinions about prostate cancer screening. Men need to inform themselves of these uncertainties as they decide whether to be screened.