5 Golden Rules for Prostate Cancer Screening

The Prostate Cancer Doc

5 Golden Rules for Prostate Cancer Screening

By Gerald Chodak, MD

Published Mar 6, 2014

The debate about prostate cancer detection has not gone away. Several medical studies have been updated with debate centered around the odds of benefitting or being harmed. Medical organizations vary in their suggested guidelines leaving many individuals more confused than helped. Another new report has appeared, offering five “Golden Rules” aimed at providing good advice for men with prostate cancer.

Rule 1. Don’t get a blood test to measure Prostate Specific Antigen (PSA) without first signing a consent. This is excellent advice and is the most important rule but it should contain balanced information about the odds of benefitting and the odds of being harmed as a consequence of the screening and subsequent treatment.

Rule 2. Don’t screen men who won’t benefit. This also is great advice because over the past 20 years, millions men have been screened unnecessarily. Who falls into this group? It is men who either have co-morbid diseases that will shorten their life expectancy to less than 10-15 years or their age and family history are such that they are unlikely to live that long.

Rule 3. Don’t biopsy without a compelling reason. More good advice BUT it is not so easily achieved. Patients should know that NO PSA can be defined as normal. At this time, other available tests do not help decide if a biopsy should definitely be done. That means if someone has a PSA test and it is above 2.5 ng/ml, they will often be told to have a biopsy. Increasingly, some doctors are recommending a repeat PSA before doing a biopsy because fluctuations often occur. However, many men without a life threatening cancer will end up with a biopsy as a consequence of getting tested. One other option if the PSA is above this level is to wait 3-4 months, have another PSA and then decide if it is rising fast enough to warrant a biopsy.

Rule 4. Don’t treat low risk disease. This sounds great but it has been very difficult for many men to accept. In most cases, a man’s partner will be very uncomfortable knowing their man has cancer and it is being left untreated. About 60-70% of new cases fall into this low risk category (PSA less than 10 ng/ml, normal rectal exam or a small cancer and a biopsy showing no aggressive cancer cells) but probably less than 10% choose this conservative approach. That makes it difficult to say to someone, “just because you get tested and diagnosed with cancer does not mean you have to be treated.” Men should think about how they might respond to hearing they have cancer before ever getting the PSA test done.

Rule 5. If you have to treat, do so at a high volume center. This rule is likely to upset many general urologists who treat this disease. But the fact is that experience counts with all treatments for localized disease. Studies have shown that doctors doing small numbers of radical prostatectomy have, on average, higher complication rates than more experienced doctors. Recent studies suggest that doctors need to do a few hundred robotic prostatectomies do gain proficiency and get good, consistent results.

These suggestions are worth considering given the ongoing debate about the net benefit of screening. Men should remember that while some will benefit from screening and treatment, a much large percentage will not benefit or be harmed by the treatment. Making an informed decision is the best a man can do.