Father’s Day always seems to be a good time to let Dad know how much you care about him by reminding him to keep healthy – this includes getting screened for prostate cancer.
For men age 50 and older, the question is: should you get screened or not? There is a simple blood test called PSA (Prostate Specific Antigen). The timely use of PSA plus a simple physical exam called digital rectal exam (DRE), will pick up most cases of prostate cancer before it gets out of hand. If prostate cancer is caught early, the chance of dying from the disease is very low. Yet, the answer from a federal government task force in the fall of 2011 was that prostate cancer screening should not be done based on two randomized prospective studies. In medicine, randomized prospective studies are the best ways to answer questions. Unfortunately, rather than clarifying the issue, the blanket recommendation from the task force caused more controversy and confusion.
The first study – known as the PLCO (prostate, lung, colon, ovarian cancer) study -- was published in 2009 in the widely respected medical journal New England Journal of Medicine. In this study, 76,693 men between 1993 and 2001 were randomized into “screened” and “unscreened” groups. In the “screened” group, men received PSA testing for six years and DRE for four years (PSA cut-off of 4.0 ng/ml). With a follow-up between seven and ten years, there was no significant difference in prostate cancer deaths between the two groups.
Although this was a well-designed study, the concern is in how the study was executed. First, in the “unscreened” group, approximately 40 to 50 percent of the men received PSA testing sometime during the study. How is this possible? It turns out that these men who received PSA testing outside the study had multiple doctors (in addition to urologists, primary care physicians, cardiologists, etc), and the doctors not involved in the study ordered the PSA tests.
Second, in the “screened” group, the compliance was 85 percent. That means a little less than 1 in 5 men in the “screened” group actually did not get the PSA test. The authors of the PLCO study recognized these shortcomings and in the most recent update published in the Journal of the National Cancer Institute in 2012, the “unscreened” group was changed to “opportunistic screening” group.
The second study was published in 2009 by a European consortium in the New England Journal of Medicine. This study was significantly larger than the PLCO study and enrolled 182,160 men. In the “screened” group, the prostate was biopsied if the PSA number was greater than 3.0 ng/ml. After an average follow-up period of approximately nine years, the risk of prostate cancer deaths decreased by 20 percent in the “screened” group. A more detailed analysis revealed that approximately 1,410 men need to be screened to save one patient and 48 men need to be treated to save one patient over the duration of the study.
In the most recent update of this study that was published in March/2012 in the New England Journal of Medicine, the benefit of prostate cancer screening further increased after an 11-year follow-up: risk of dying from prostate cancer decreased by 29 percent and now 37 men need to be treated to save one life. It is fair to assume that the benefit of prostate cancer screening will continue to rise with a longer follow-up in this study.
So what should you do?
Should you gamble when the odds of dying are approximately one in 37 over 11 years? From my perspective as a urologic-oncologist who deals with prostate cancer daily, I will not recommend playing the odds. I recommend annual PSA test and digital rectal examination. Talk to your doctor about what age to begin (while many experts say 50, for you it could be earlier if you are at a higher risk and/or have a family history).
Robert Wood Johnson University Hospital and The Cancer Institute of New Jersey (CINJ) offer free prostate cancer screenings each September. This year’s screening event will be held on September 18, 19, and 20. To register, call 1-888-MD-RWJUH or 1-888-637-9584.
Courtesy of Isaac Yi Kim, M.D., Ph.D., executive director of the Gallo Prostate Cancer Center at The Cancer Institute of New Jersey (CINJ) and an associate professor of surgery at UMDNJ-Robert Wood Johnson Medical School (RWJMS).