It seems that every month there is more controversy in the media on prostate cancer screening. Believe me, medical professionals are just as confused as is the public. Depending on which medical advice you listen to, screening is either a good idea and recommended, or it is not reliable and should not be performed. What should you do? There is unfortunately no easy answer, but the more you know about prostate cancer and the risks and benefits of screening, the better you will be able to make your own decision. I have this discussion with patients several times a week, and I will give you the same advice that they receive. I thought it might be most useful to do this as a question and answer format, much as it would be at an office visit.

Should I be screened for prostate cancer? This is the most common question and the most difficult to answer. Why? Because not even the different medical societies can agree. Obviously those at increased risk should strongly consider being screened. This would include those with a close family member with prostate cancer, such as a father or brother. These individuals carry a genetic risk of developing prostate cancer earlier and a more aggressive type. African-Americans also have a higher risk of prostate cancer. These individuals should consider having at least a baseline PSA at age 45. As urologists, we recommend all patients have a baseline PSA starting at age 50. However, the U.S. Preventative Task Force previously has recommended to not perform routine screening in the general population. They state that to find one “significant” cancer, 1,000 men must be screened. Note that I said “significant.” This means a cancer that would potentially be lethal if untreated. Screening would find more cancers, but some of these would be slow-growing and in men who, because of their advanced age or poor health, may well die from other causes before their prostate cancer would ever grow. The American Urologic Association has since revised their guidelines on screening. Although they still recommend screening, the frequency and timing of PSAs has changed.

What does screening mean? We recommend a PSA blood test as well as a rectal examination. Many patients want to know if they can just skip the rectal exam. Unfortunately, not all cancers raise the PSA level, and the only way they can be diagnosed is by examining the prostate. I will find a few cancers every year in this way. The good news is that this only has to be done once a year. Believe me, I moan and groan just as much as the next guy when it is my turn. It’s just one of those things we have to do.

What is a PSA? Simply put, PSA is a protein in the bloodstream. Normal prostates make it in small amounts; prostate cancer makes it in large amounts. The normal range is from zero to four. Any number above four is abnormal but does not necessarily mean you have cancer. PSA is a wonderful test in that we can pick up a cancer very early, often months to years before we would find it at a rectal exam. However, that sensitivity comes at a price. Other things can affect PSA. Recent sexual activity, prostate problems such as difficulty voiding and particularly infection may affect the level.

If the PSA is not reliable, why even do one? At present, this is the only way we have of detecting prostate cancer early. Although the data is not clear, most urologists feel that in the PSA era, we have been able to increase our cure rates and treat the disease at an earlier stage. In fact, a large European study did demonstrate that men whose cancer was detected by early screening did have a higher survival rate. I feel that some of the controversy about PSA has to do with how your doctor interprets the test. What that means is that you have to interpret the PSA level as it applies to each individual. A PSA of four in a 41-year-old man means something totally different than it does in a 77-year-old man. Unfortunately, you cannot apply the zero-to-four scale in the same way for each patient. This is where you should discuss your PSA with your physician. Not everyone who has a PSA more than four needs or should have a biopsy. I have heard that almost all men, if they live long enough, will get prostate cancer. Your lifetime risk of developing prostate cancer is about one in 11. Does that mean that all those men will need treatment? No. Again, each individual must be individually considered. Your age, any additional medical problems, family longevity and aggressiveness of your cancer all weigh in on the decision to treat your cancer. Many patients who have prostate cancer will never require treatment and their cancer will never be a threat to them. That is a discussion your urologist and you would need to have.

What is the downside to screening? For most, the worst thing will be the needle stick for the blood test and the rectal exam. If your PSA is high, you might need a biopsy. This is about a 10- to 15-minute procedure performed in the office. An ultrasound probe is inserted in the rectum, a local anesthetic is administered and a needle is used to take prostate tissue. The risks include bleeding and infection. Opponents to screening point out that some individuals will have biopsies that don’t need them because they don’t have cancer. Unfortunately, that will always be true because nothing in life is 100 percent. I try to be as sure as I can that when I do a biopsy it is as absolutely necessary as possible. However, the happiest patients are those with a negative biopsy.

If I have cancer, what can be done? The good news is that today there is even more that can be done than ever. From watchful waiting to surgery to ultrasound to radiation to robotics, the choices are myriad. Once again, every patient is different and what might be best for your neighbor may not be best for you. This requires a long discussion with you, your urologist, possibly oncologist or radiation oncologist. Prostate cancer, in general, is a slow-growing cancer, and the one luxury you have is time to make a fully aware and educated decision about your treatment.

The best advice I can give you is to discuss prostate cancer screening with your healthcare provider. They are best suited to help you make a decision about prostate cancer screening.

 

Dr. Michael Crawford is an urologist with Vidant Urology of Washington, located at 1202 Brown St. and can be reached at 252-946­0136.