By Brendan Curti, M.D., oncologist and director of genitourinary oncology research, Robert W. Franz Cancer Research Center in the Earle A. Chiles Research Institute at Providence Cancer Center
To screen, or not to screen? For men concerned about their risk of prostate cancer, that is the question.
At least 18 different medical associations have made recommendations regarding the prostate-specific antigen (PSA) test that is used as a screening tool for prostate cancer, yet there is little consensus among these expert panels. In the medical literature, you’ll find some studies pointing out benefits from PSA screening, and other studies suggesting that screening makes no difference.
As a physician who treats men with advanced prostate cancer, my own bias is that screening is valuable in select groups of men. If you are between the ages of 50 and 70 and you are not getting screened yearly, I would at least encourage you to talk it over with your physician. Here are some things to consider.
PSA as a marker for prostate cancer has its limitations. Both cancerous prostate cells and normal prostate cells produce PSA. Higher than normal levels of PSA in the blood could be an indication of prostate cancer – but not always. Elevated PSA levels can be a normal response to inflammation, infection, prostate enlargement or other benign factors. To make matters more confusing, while low levels of PSA generally suggest the absence of cancer, that’s not true in every case, either. Up to 15 percent of men with normal PSA levels may have prostate cancer on biopsy; however, most of these cancers are not aggressive.
Despite these limitations, however, doctors still can glean important information from the PSA test by comparing results from year to year. A record of how fast your PSA levels change – known as “PSA velocity” – can be very useful in detecting a problem as it is emerging. A gradual rise in PSA is normal as a man ages and his prostate grows larger, but a significant rise in PSA from one year to the next could indicate an emerging cancer, and should be followed up with further screening.
The usefulness of PSA increases in value when combined with a digital rectal exam – a physical examination of the prostate. The two tests together provide two types of information that, in combination, can help catch more cancers than either screening method alone. Any prostate abnormality found on physical exam, particularly if accompanied by high PSA levels, should be followed up with a biopsy, which is the only way to confirm a diagnosis of prostate cancer.
Concerns and fears about whether and how to treat prostate cancer, if it is found, are another reason why some men choose to avoid screening altogether. Why treat a cancer that might grow so slowly that it wouldn’t cause problems anyway? And if you would choose not to treat, why choose to know about it? This is certainly a valid argument for some men, especially those who are older and who have other health conditions that pose a greater threat to their mortality.
But for younger men in good health, and for those with a strong family history of prostate cancer, finding and treating cancer early can mean a much longer life. Recent studies published in the New England Journal of Medicine and in the Journal of the American Medical Association show that, for men in otherwise good health, aggressive, up-front treatment yields better outcomes and extends life longer than watchful waiting or more conservative management. (As with screening, treatment strategies should be custom tailored to each person’s detailed findings on exam and biopsy and overall medical health.)
Medical, surgical and radiation treatments for prostate cancer all have seen recent advances. For instance, a robotic surgery system used by urological surgeons at both Providence Portland Medical Center and Providence St. Vincent Medical Center can reduce hospital time and speed recovery following surgery to remove the prostate. Significant advancements have been made in radiation for localized prostate cancer, as well. And there is a long list of improvements happening in medical treatment, especially for men with more advanced disease.
In addition to improvements in traditional treatments, research teams at Providence Cancer Center and throughout the country are making great strides into new avenues for treatment, such as immunotherapy, which boosts the immune system’s ability to fight cancer. One of my patients, John Kohlenberger, recently spoke at our annual Positive Perspectives luncheon. John told the compelling story of how participating in cancer research has allowed him not only to survive, but to remain active with a good quality of life, for nine years following his diagnosis of stage 4 prostate cancer. His case may not yet be the norm, but it certainly offers cause for hope for many others.
Most medical organizations at least agree that it is a good idea for men to talk with their physicians about prostate cancer screening. For men who choose to get screened, some generally accepted guidelines are as follows:
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