Prostate Cancer: When Should Men Get Screened?
by Josh Fink, MD
In the last few years, the advice on prostate cancer screening has been very confusing for patients, and front of mind for internists and urologists. It’s a pressing concern because in 2012 there were 28,000 deaths from prostate cancer. However, the best approach to screening is still controversial.
In 2009 and 2012, researchers published key trials on prostate cancer screening, and the results only added to the controversy. A large study done in the United States failed to find a benefit to early prostate cancer detection, whereas a large European study did. However, when I say the European study “did” find a benefit, it wasn’t that reassuring. According to a February issue of the Annals of Internal Medicine, the European study found that for every 1,000 men screened, 37 cases of cancer would need to be detected and treated to prevent one death.
You might think that finding a tumor early would always improve survival. But early detection can create a mirage called “lead-time bias.” What does that mean? It’s not a pleasant thought, but imagine you are tied to a train track. Whether you hear the train whistle early or when the train is close to you, the train will still arrive at the same time. Some cancers are just like that train: They become deadly at a certain point, and finding the cancer earlier doesn’t actually help the patient live longer. The research suggests that early detection through prostate screening may only be increasing the amount of time that men are getting treatment, but not how long they live.
Another issue is that, because some prostate cancers are very slow growing, a man could die of other causes well before the cancer becomes deadly or even causes symptoms. Now consider that the treatment for prostate cancer can have serious side effects, such as impotence and incontinence. What worries doctors and researchers is that a man might get treatment that won’t increase his lifespan, and yet would negatively impact his life due to side effects.
This concern and confusion explains why men need to have to have a conversation with their doctors about when they should start prostate cancer screening. We can identify risk factors for prostate cancer: Increasing age, a family history of the disease, and being African American all increase a man’s risk. And there are symptoms of prostate cancer that indicate a man should see his doctor right away: These include frequent urination, pain or burning while urinating, a weak or interrupted flow, and constant pain in the lower back, pelvis, or thighs. The bottom line is that while we really don’t have an optimal screening test for prostate cancer, a man can discuss his risk factors with his doctor and weigh the pros and cons of screening. And if cancer is detected, the patient and doctor can then decide on aggressive care such as surgery, radiotherapy, cryotherapy, and seed implants, or an active surveillance, watch-and-wait approach.
In the mean time, researchers continue to study prostate cancer, screening, and treatment. One such study is ongoing at Northern Westchester Hospital. The MEAL — Men’s Eating And Living — study is enrolling men with a diagnosis of prostate cancer to track their eating habits to see if something as simple as making nutritional changes can make the “watch and wait” approach a more reasonable and less scary option for most men.
Editor’s Note: Joshua Fink, MD, is Director of Clinical Trials at Northern Westchester Hospital. Learn about our Clinical Trials Program and current active trials by visiting www.nwhc.net/ClinicalTrials