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Doctors grapple with prostate cancer screening guidelines

For years, the PSA test has been the standard method for early detection of prostate cancer, which strikes one in six men.

But recently, the U.S. Preventive Services Task Force, a federal advisory panel, said the test that checks for prostate-specific antigens should not be routinely given to healthy men because it doesn't save enough lives to warrant all the extra treatment and stress stemming from the tests. Some men die of complications from surgery to remove the prostate, and many others suffer side effects. Others worry for years they will develop cancer after their tests.

But the recommendation is not sitting well with some doctors who still believe there is value in screening younger men. One who says the tests cut the death rate from prostate cancer is Dr. Ronald Tutrone, chief of urology at Greater Baltimore Medical Center and medical director of Chesapeake Urology Research Associates.

How common is prostate cancer?

Prostate cancer is the second-leading cause of cancer death in the United States behind lung cancer. One in six men will be diagnosed with prostate cancer during his lifetime. This year, about 241,740 men will be diagnosed with prostate cancer and 28,170 will die from this disease. African-American men and men with a family history of prostate cancer have a 60 percent greater risk of developing prostate cancer.

Why did the task force decide the PSA test did more harm than good?

The task force, which did not include any urologists or oncologists, concluded that "screening may benefit a small number of men but will result in harm to many others." Its opinion was based on possible side effects from surgery for prostate cancer, such as incontinence or erectile dysfunction, and side effects from radiation, such as bowel problems. The task force did not acknowledge that since PSA was introduced as a screening test in this country, prostate cancer mortality has dropped 40 percent. The task force did not take into account a large screening study, the European Randomized Study for the Screening of Prostate Cancer, that published its updated findings in the March New England Journal of Medicine demonstrating a 21 percent survival advantage to PSA screening for all patients and for those with longest follow-up (more than 10 years) this increased to 38 percent. The Goteborg Randomized Population based Prostate Cancer Screening Trial found deaths from prostate cancer dropped 44 percent among screened men over a 14 year period when compared with unscreened men.

Aren't there serious and lifelong complications from this treatment?

Radical prostatectomy can be associated with urinary incontinence (8 percent to 10 percent) and erectile dysfunction (50 percent to 70 percent), while radiation can be associated with bowel or bladder problems, though this occurs in fewer than 10 percent. Many of the complications are related to the age of the patient and the cancer stage, and can vary in severity.

How do you now decide which cases need treatment and which don't?

The decision to treat prostate cancer is a decision that needs to be made by a patient and his physician. It is critical that a patient understands the nature of the disease and what all of the options are, including the adverse effects and outcomes before he can make an informed decision on whether and how to treat the cancer. Many factors come in to play such as the stage and aggressiveness of the cancer as well as the age and general health of the patient.

How will cancer be diagnosed if men don't have a PSA test?

PSA is not a perfect screening test, however it is the best test we have. Currently, over 90 percent of prostate cancers are detected due to a rise in the PSA. Of all prostate cancers detected, less than 10 percent can be felt on digital rectal exam. Prior to the use of PSA as a screening test, men would present with rock-hard prostates on rectal exam or painful metastases to their bones. Treating advanced prostate cancer is far more expensive than definitive treatment for localized prostate cancer over the course of a man's life. Although in the short term (5-10 years), not screening for prostate cancer may save money, in the long run it will be far more costly to our health system and result in a greater number of men dying needlessly and painfully from advanced prostate cancer. We do not need to go back 30 years in our diagnosis and treatment of prostate cancer. Instead we need to forge ahead and develop better ways to detect those prostate cancers that will behave more aggressively and refine our treatments with less invasive and more effective methods to treat this disease.