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Doctors differ on screening to detect prostate cancer

By Helena Oliviero and Steve Visser

Atlanta Journal-Constitution

Prostate screening tests detect prostate cancer early, but questions about whether the tests do more harm than good have made them one of the most hotly debated areas of medicine.

Some doctors and researchers believe testing for PSA, which stands for prostate-specific antigen, leads to unnecessary, costly and even harmful medical procedures because so many early diagnoses are slow-growing cancers that don’t require immediate treatment. But men typically demand care once they hear the “C” word.

Those on the other side say PSA screening remains a valuable tool for detecting cancer early and saving lives.

Last month, the American Urological Association reversed course and no longer recommends routine screening for men 40 to 54 years old, who face an average risk of getting prostate cancer. It said testing should be considered primarily for those 55 to 69. Even then, a PSA test should not be automatic. Men should talk to their doctors about the benefits and risks and “proceed based on their personal values and preferences,” the association recommended.

The urology group’s announcement followed the 2011 recommendation by the United States Preventive Services Task Force, arguing against routine screening in healthy men because it often leads to unnecessary biopsies and surgery as well as life-altering complications such as impotence and incontinence.

A problem with screening is that PSA levels can be high, indicating cancer, even when a man doesn’t have it. Another issue is that if a biopsy detects cancer, it is often very slow-growing and, as cancers go, relatively benign.

In other words, a PSA test was taking healthy men and turning them into cancer patients who underwent radiation therapy, surgery and other invasive procedures for something that would never cause death or even lead to any symptoms.

But even seemingly benign cancer can turn serious. And some men want to turn back any risk of cancer immediately.

Four years ago, Michael LeBlanc, 62, didn’t even think about waiting to treat cancer detected in his prostate. Whether the cancer was slow-growing or more aggressive was a moot point, he said.

“Although it’s slow growing, what says tomorrow it won’t change?” said LeBlanc. “It’s like calling 911 and you say there is a man who broke into the house but he looks like such a nice guy, I don’t think he’s going to hurt us right away. A home invasion in a home invasion. Cancer is cancer. You don’t dillydally with that.” LeBlanc underwent robotic surgery to remove his prostate. He said an analysis indicated the cancer “had consumed my prostate.” Exercise, he said, helped him make a full recovery.

Dr. Otis Brawley, chief medical officer for the American Cancer Society, has long called for more caution with prostate cancer screening, speaking against mass screenings such as the ones offered by health companies at shopping malls.

Many patients, he said, don’t fully realize the potential complications associated with PSA testing.

“My whole campaign has not been one that men should not be screened,” he said. “Let the man know the pluses and minuses, and what we know about the disease and the screening of the disease and then let the man decide,” Brawley said.

That decision, he said, should be based on weighing the benefits versus potential harm of screening. Research of men 55 to 69 suggests PSA screening may prevent one death from prostate cancer for every 1,000 men screened at two-to-four year intervals over a 10-year-period, according to the American Urological Association. At the same time, many men who get the screening will be harmed because of treatments that can lead to health complications. Even a biopsy poses a risk of infection, for example.

Doctors may recommend “active surveillance” for men with low-risk prostate cancer tumors, in which the tumor is regularly monitored rather than treated. But getting patients to watch and wait is difficult.

“Part of it is a reaction to cancer. The 1970s Nixon War on Cancer and there’s this concept that all cancer is bad,” said Dr. Martin Sanda, chairman of the Department of Urology at Emory University School of Medicine and director of the Prostate Cancer Center in Emory’s Winship Cancer Institute. “But now we are pushing the envelope. Many of these can be watched.”