Wednesday, Aug. 20, 2008

Open forum: Benefits of prostate cancer screening should outweigh risks

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by Shrey Desai

It is hard to imagine that screening for early detection of prostate cancer could be harmful to certain individuals. So, it is important for us to understand why the U.S. Preventive Service Task Force (USPSTF), a federal government panel, recommended against doing prostate cancer screening for men more than 75 years of age due to concerns regarding its potential harm.

Also, prostate cancer is an important public health problem as it was the most commonly occurring cancer in the Montgomery County as per the latest Cancer Report published by the Maryland Department of Health and Mental Hygiene. Montgomery County had the second highest number of new prostate cancer cases in Maryland as per the same report.

Prostate cancer screening entails doing a rectal exam and a simple blood test, Prostate Specific Antigen (PSA). The main goal of a screening test is to detect diseases before the symptoms develop. Mammography is an example of such a screening test for the breast cancer.

A good screening test is able to detect disease at an early stage and early treatment should result in reduction of risk of death. There is a general consensus that the prostate cancer screening test can detect cancer at an early stage. But there has been a long standing controversy as to whether or not the early diagnosis of prostate cancer does always help to reduce risk of death. The reason is that some of the early, slow growing prostate cancers may not cause any symptoms or even death.

The concerns about doing prostate cancer screening is related to potential harm of further tests and treatment, which your doctor usually obtains after having abnormal screening test. Potential side effects of the treatment are impotence, urinary incontinence and death. Therefore, it is important to have guidelines for doctors and patients to weight risks and benefits of screening test before they have one.

The USPSTF is an independent panel of experts who systematically review medical literature to provide guidelines regarding preventive services. It recently concluded that the harm of doing prostate screening for men more than 75 years of age outweighed the benefits. USPSTF found a small, if any, benefit of early detection, but substantial harm (as mentioned above) of screening in men more than 75 years of age. Many of these men with abnormal results may ultimately die "with" prostate cancer rather than die "due" to cancer, if they choose not to have treatment. Considering the evidence, the panel recommended against doing prostate cancer screening for men more than 75 years of age.

Unfortunately, there is a disagreement among various medical professional associations regarding the matter. The American Cancer Society and American Urologic Association continue to recommend screening after discussing risks and benefits with the patients irrespective of their age. Additionally, the USPSTFS found insufficient evidence to recommend for or against the screening for men younger than 75 years of age. This disagreement reflects lack of good quality evidence regarding the issue of prostate cancer screening.

So, what is the bottom line? First, you should discuss the risks and benefits of prostate cancer screening with your doctor, especially if you are older than 75 years of age. The benefit of the screening should overweight the risks if you have the test. At the same time, you should continue to have screening for other diseases such as colon, cervical and breast cancer because there is consensus among all major professional associations regarding benefits of such testing. Also, these recommendations are only for those patients who do not have any symptoms. You should seek medical attention if you have any symptoms related to prostate cancer.

Shrey Desai, MD, MPH, of Silver Spring is an internist who is also trained in the area of public health. He is currently working at the Johns Hopkins University.