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Commentary: Tackling Prostate Cancer Screening Controversies—5 Things Men Should Know

Commentary
09/22/21 Leonard G. Gomella, MD, The Bernard W. Godwin Professor of Prostate Cancer and Chairman, Department of Urology, Sidney Kimmel Cancer Center at Thomas Jefferson University

As we get older, making smart choices about our health means getting proactive about identifying potential conditions or complications. Most of the time, the earlier you identify a change in your health, the more effectively you’ll be able to tackle those challenges and stay healthy.

But that’s not always the case. In some instances, testing and screening procedures have pros and cons. Physicians, advisory groups, and patients have different opinions about when and how to conduct these tests.

Few tests are as controversial as prostate cancer screenings.

The prostate is a gland found only in men located just below the bladder. As men get older, many experience benign growth and an enlarging of the prostate gland due to non-cancerous swelling. A smaller percentage of men will develop a malignant growth in the prostate that can spread cancer to other parts of the body if it is not found early. In the United States, a man’s lifetime risk of being diagnosed with prostate cancer is 17% and the risk of death to due to prostate cancer is about 3%.

The screenings designed to detect this cancer early are quite effective – and quite controversial. For men looking to take proactive steps to protect their health, figuring out if and when a prostate cancer screening is right for them can be confusing and stressful. This screening discussion involves finding cancers early before they spread outside the prostate. Here are five things to keep in mind while navigating these considerations.

1. Prostate Screenings Have Changed in the Last Several Decades

The first thing to understand about prostate screenings is that they are different than they were a generation ago. In the past, screenings involved a rectal exam to physically examine the prostate for hard areas to determine if a biopsy was warranted. Today, and for the last several decades, physicians have increasingly relied on a blood test to measure a substance made by your prostate called PSA.

An elevated PSA level is a potential indicator of cancer, however there are other things that can cause elevated PSA. It’s important to note that an elevated PSA can be due to conditions such as a prostate infection or simply an enlarged benign prostate. If you have an elevated PSA blood test, your doctor may order tests such as an MRI exam of the prostate or other newer tests to indicate the possible presence of cancer. While you doctor may rely on these other tests, the only way to diagnose prostate cancer is with a tissue biopsy.

2. There are Pros and Cons to Prostate Cancer Screenings

Before exploring different screening recommendations and criteria, it’s important to understand why the screening test is so controversial. The reality is, there are benefits and downsides to prostate screenings, but it can benefit many men. The greatest benefit is detecting aggressive forms of prostate cancer early before they spread beyond the prostate. In these instances, treating the cancer can increase quality of life as well as quantity of life by treating and preventing the cancer from spreading.

At the same time, the screening itself and potential biopsy presents some risks, including bleeding and infection. What’s more, many prostate cancers tend to grow relatively slowly, and there is a concern that the side effects of treatment, which can include erectile dysfunction, urinary incontinenceor irritation of the bowel, may be more damaging than leaving the cancer untreated. It’s this balance between proactive detection and reducing treatments with life altering side effects that is at the heart of the prostate screening controversy.

3. Early Prostate Cancer Doesn’t Always Require Surgery or Radiation Therapy

It’s important to note that just as screenings have evolved, our understanding of the progression of prostate cancer and treatment strategies have advanced as well. Unlike 20 years ago, an early prostate cancer diagnosis today doesn’t automatically prompt aggressive treatment.

Physicians today may recommend active surveillance ( often referred to in the past as watchful waiting). The patient with newly diagnosed early and non-aggressive prostate cancer will undergo periodic monitoring. Many men can avoid treatment unless the cancer is progressing or changing. This can be a stressful situation for men to find themselves living with an “untreated” cancer, but it’s important to understand the true risks and benefits and talk to a doctor about the best way to proceed with treatment or surveillance.

4. Screening Recommendations Vary Significantly

There is no single broadly accepted recommendation for prostate cancer screenings. After weighing the opportunities and risks the screenings present, different professional groups have put forth different recommendations. Organizations including The National Comprehensive Cancer Network, the American Urological Association, and the American Cancer Society recommend screening some men with certain caveats.

Specific recommendations do vary by group, but screening is generally considered in men with a life expectancy of at least 10 to 15 years who are also older than 50 and in some who are younger who have risk factors, such as being African American or having a family history of prostate cancer or breast cancer. Benefits of screening may decrease with age.

Other organizations like the American Academy of Family Physicians are not in favor of prostate cancer screening. Many patient-focused organizations and resources also focus on the risks of screenings. Other groups, including the United States Preventive Service Task Force that have opposed prostate screenings in the past are beginning to suggest screening may provide benefits in some men.

5. Men Should Make the Decision for Themselves – with Input from a Doctor

Given the complications and controversies surrounding prostate cancer screening, virtually all major organizations agree that no one should be screened without first having an in-depth conversation with their doctor to discuss the uncertainties, risks, and benefits.

At the end of the day, it’s a personal choice. If you’re concerned about prostate cancer and are of a certain age, if you’re African or African American, or if you have a family history of prostate cancer or breast cancer, you should have an informed discussion with your doctor.

For more on prostate cancer and screenings considerations, visit the Manuals page or the Quick Facts page on the topic.
Leonard Gomella, MD

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