New guidelines for prostate cancer screening were issued Wednesday, March 3, 2010, by the American Cancer Society. In reporting on these ‘changes,’ the L.A. Times, reminds us that “prostate cancer is the most common cancer in men after skin cancer, affecting 192,000 men each year and killing 27,000.”
In essence, these appear to be the significant features of these new guidelines: (1) physicians should better educate men about both the risks and benefits of using the PSA test for screening; (2) less use of a rectal exam for screening; and (3) a cutback in the use of “mass screening” for prostate cancer such as at community health fairs, community centers, and the like.
Several recent studies have suggested that large numbers of tumors identified by PSA screening are inconsequential and that biopsies and treatment produce more harm than those tumors would.
The L.A. Times quotes Dr. Otis W. Brawley, chief medical officer of the American Cancer Society, who said the new guidelines were not that different from those issued in 1997 and 2001. They are more a change in emphasis of informed consent to patients and direction to health care providers, who do such screening, to inform those patients of the relative risks and complications (of unnecessary treatment) associated with screening.
Now, Dr. Brawley added, “we have two clinical trials that very vividly illustrate the uncertainties associated with screening,” which makes it even more important for men contemplating the PSA tests to understand the risks. Those major trials showed that PSA screening does not lower the risk of death from prostate cancer and might actually increase it slightly, perhaps from unnecessary treatments.
The risks are not in the screening procedures themselves (PSA and/or rectal exam); they lie in what follows from screening – biopsies, radiation, prostactectomies and other forms of treatment. The goal of the new guidelines – a better educated patient on the relative risks and complications of screening and the resultant treatment that may follow (e.g. urinary incontinence and impotency) – is not embraced by all in the spheres of medicine and patient health.
Skip Lockwood, president of Zero — The Project to End Prostate Cancer, said that calls to end the digital rectal exam were “kind of nuts. . . . The whole concept that you would do anything to reduce the amount of information you have does not make sense to me.”
From the specialists in urology, there is also this admonition:
Dr. S. Adam Ramin, a urological oncology specialist at St. John’s Health Center in Santa Monica, said that the cancer society guidelines placed too much emphasis on whether the tests saved lives and not enough on whether they prevented complications from tumors, such as leaking of urine, incontinence, bone pain, anemia and weight loss.
“Although it is true that treatment will not necessarily save a lot of lives, it does prevent complications,” he said.
While the American Cancer Society is not advocating the termination of prostate cancer screening by any means, it is expressing a very worthwhile concern – are patients who are screened and advised of positive test results fully aware of the risks involved in treatment as well as the benefits (lessening of tumor complications, for example) when making potential life-altering decisions about treatment options? The bottom line – have the test, get your results but understand in a meaningful way what your options are and what risks you run - THEN decide.