Prostate cancer
Prostate cancer is the second most common cancer in men (after skin cancer) and the second leading cause of cancer death in men (after lung cancer). As many as 1 in 5 American men will develop prostate cancer during his lifetime. An American man has about a 3 percent chance of dying from this disease. Most cases are diagnosed after age 65. Some prostate cancers are quick and deadly, but most grow slowly and are never a serious threat. When prostate cancer is caught in its early stages, it can be effectively treated and cured.
Expert panels are cautious about recommending universal screening for prostate cancer. Many complicated issues are being discussed, including, for example, how treatment can be more harmful than the cancer itself (about 1 in 4 is slow growing and may not cause any trouble), how current technology cannot tell a slow-growing cancer from a fast one, and how a man’s health or life expectancy may never be affected by the cancer but the treatment’s side effects (impotence and incontinence) are often serious problems. The tests have known limitations (for example, they do not detect all cancers equally well and about one third of positive results do not prove to be cancer). Because mass screening is likely to be expensive, solid evidence is required to justify it.
Some groups urge testing because the majority of evidence, though not conclusive, shows that early detection of prostate cancer saves lives. Since diagnostic blood tests for prostate-specific antigen (PSA tests) started to be used in 1990, more prostate cancers are being caught before they spread to other organs and become difficult to cure. The experts do not have enough information to conclude, however, that this is a direct “cause and effect” relationship.
The age at which screening should begin is also not known with certainty. If you have risk factors, getting tested in your 40’s is advised. The American Cancer Society suggests this:
Start testing at age 45 (age 40, say the National Comprehensive Cancer Network and the American Urological Association) if you are a man of African descent or have a father or brother who was diagnosed at an early age.
If more than one relative was affected at an early age, you could begin at age 40; then, depending on the results, get tested again at age 45 or earlier as results warrant.
The National Cancer Institute, the U.S. Preventive Services Task Force, and the American Academy of Family Physicians have refrained from recommending for or against routine prostate cancer screening for those at low risk. They are concerned about doing more harm than good. Through studies being conducted over the next 5 to 10 years, the medical community hopes to shed light on the issues so firmer conclusions can be reached.
Many scientific and medical organizations agree that men middle aged and older should routinely receive information. The American College of Preventive Medicine, for example, recommends the following:
Men age 50 and older with a life expectancy greater than 10 years, even with no known risks, should be informed by their health care provider about the pros and cons of prostate cancer testing and treatment, and they should be helped to understand their risks and options.
The American Urological Association advises using the digital rectal exam and then the PSA test, in combination for the broadest detection of cancer in its early stages. Like the other experts cited above, this physician group stresses the need for individualized decision-making and says, for most men, age 50 is a good time to begin the discussion.
The American Cancer Society goes a little further, recommending older men be offered both tests each year:
Men age 50 and older who have a life expectancy of at least 10 years should be offered both a PSA test and digital rectal exam; men who ask their physicians to decide for them should be tested.
The National Comprehensive Cancer Network recommendation is a little narrower:
Men age 50 and older with a life expectancy of at least 10 years should have the rectal exam each year and be offered the PSA blood test.
Not only do the groups recommend slightly different approaches, they also have slightly different opinions on how often to repeat the tests. The American Cancer Society recommends yearly tests, the National Comprehensive Cancer Network says some men may only require a retest every 2 years, and the U.S. Preventive Services Task Force says testing every other year may prove to be as good as testing each year.
On what age to stop, the National Comprehensive Cancer Network offers the following:
Most experts believe men over age 75 have little to gain from PSA testing.
Information is available from the National Comprehensive Cancer Network at http://www.nccn.org/patients/patient_gls.asp that can help you understand why early diagnosis and treatment decisions are best made by individuals.
A decision guide is also available at http://www.cdc.gov/cancer/prostate/decisionguide/index.htm.
Your health care provider is best able to help you weigh the pros and cons of screening based on your age, life expectancy, family history, race, and previous detection results.
Sources
American Academy of Family Physicians. Prostate cancer: what you need to know. Available on the Internet at http://www.familydoctor.org/x5387.xml. Accessed July 21, 2004.
American College of Preventive Medicine. Screening for prostate cancer in american men: American College of Preventive medicine practice policy statement. 1998. Available on the Internet at http://www.medem.com. Accessed August 5, 2004.
American College of Preventive Medicine. Understanding prostate cancer screening. 2001. Available on the Internet at http://www.medem.com. Accessed July 21, 2004.
American Urological Association. Prostate-specific antigen best practice policy. Oncology. 2000 Feb;14(2). Available on the Internet at http://www.cancernetwork.com/journals/oncology/o0002e.htm. Accessed August 5, 2004.
Berg AO, for the US Preventive Services Task Force. Screening for prostate cancer: recommendations and rationale. Ann Intern Med. 2002 Dec 3;137(11):915-916. Available on the Internet from the National Guideline Clearinghouse at http://www.guidelines.gov/summary/summary.aspx?doc_id=3404&nbr=2630. Accessed July 19, 2004.
JAMA Patient Page: weighing difficult choices: treatment of prostate cancer. JAMA 1998 Sep 16;280(11):1030. Available on the Internet at http://www.medem.com/medlb/articleslb.cfm?sub_cat=321.
Accessed August 5, 2004.
National Comprehensive Cancer Network. Clinical practice guidelines in oncology, version1. 2004. Available on the Internet at http://www.nccn.org/professionals/physicians_gls/f_guidelines.asp#detection. Accessed August 5, 2004.
National Comprehensive Cancer Network. Prostate cancer treatment guidelines for patients, version iii, October 2002: early Detection of Prostate Cancer. Available on the Internet at http://www.nccn.org/patients/patient_gls/_english/_prostate/index.htm. Accessed August 5, 2004.
Smith RA, Cokkinides V, Eyre HJ, for the American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53:27-43. Available on the Internet at http://caonline.amcancersoc.org/cgi/content/full/53/1/27. Accessed August 5, 2004.
Centers for Disease Control and Prevention, Cancer Prevention and Control., United States Department of Health and Human Services. Prostate cancer screening: a decision guide. Available on the Internet at http://www.cdc.gov/cancer/prostate/decisionguide/index.htm. Accessed July 21, 2004.
Centers for Disease Control and Prevention, Cancer Prevention and Control, United States Department of Health and Human Services. Screening for prostate cancer screening (slide show and talking points). Available on the Internet at http://www.cdc.gov/cancer/prostate/screening/slides/slide02.htm. Accessed July 21, 2004.
National Cancer Institute of the National Institutes of Health, United States Department of Health and Human Services. Prostate cancer (PDQ®): screening (summary of evidence). Current as of 2003 Dec 15. Available on the Internet at http://www.cancer.gov/cancertopics/pdq/screening/prostate/HealthProfessional. Accessed July 21, 2004.
National Cancer Institute of the National Institutes of Health, United States Department of Health and Human Services. Prostate cancer (PDQ®): screening. Current as of 2003 Dec 15x. Available on the Internet at http://www.nci/nih/gov/cancertopics/pdq/screening/prostate/Patient. Accessed
August 5, 2004.
