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SCREENING FOR PROSTATE CANCER - A GOOD REVIEW (November 2002) Prior to 1987, the only screening test for prostate cancer was the digital rectal examination. Although it was strongly recommended as a yearly routine, the fact is that there has never been any evidence that the digital rectal examination can change the course of prostate cancer or save lives. In 1987, the prostate specific antigen (PSA) blood test was introduced and, since then, it has been touted as an effective way of preventing severe disease or death from prostate cancer. But, a lot of authorities, including the US Preventive Services Task Force and Healthful Life, have not been convinced of the effectiveness of the PSA test. The current status of the PSA screening test was reviewed in a thoughtful article in The New England Journal of Medicine May 3, 2001 by Michael J. Barry, MD of the Harvard Medical School. Here are some of the highlights. - Most cases of prostate cancer occur in older men, but the older the men, the more likely a positive PSA test does not indicate cancer. Men with false positive tests will undergo invasive prostate biopsies that are annoying, expensive, and occasionally dangerous. - It is not clear who should be screened. There is decreasing enthusiasm for screening men older than 75 years of age. Some experts believe if men have normal PSA tests at age 65, no more screening should be carried out. Others urge starting screening at ages 40 or 45 for higher risk persons (African Americans or those with a family history). - There is, at present, no persuasive evidence that PSA screening actually saves lives or prolongs good quality life. Two major trials, one in the United States and one in Europe, will be completed between 2004 and 2009. Until then, we will not know whether PSA testing really saves lives. The review concludes "The PSA test detects prostate cancer at an early stage in many cases. At present, data are not available from large, well-designed randomized trials to determine whether early detection is beneficial or harmful or has no effects". In the face of all this uncertainty, what are the recommendations of various expert groups. The US Preventive Services Task Force recommends against testing. The American Cancer Society recommends yearly PSA tests for men 50 years of age and older who have a life expectancy of more than ten years. The American College of Physicians and the American Academy of Family Physicians say decisions about screening should be individualized after discussions with patients on potential benefits and harms of screening, diagnosis, and treatment. The idea is to get the individual man to make an informed decision. This review makes it clear we still do not know whether PSA screening really makes a difference. We do know that a large percentage of men will suffer from impotence or urinary incontinence after treatment for the PSA-detected cancers (in some studies, more than 50 percent). Those who urge PSA testing only after an informed decision on the part of individual men are being a little bit disingenuous. In reality, this approach is to shift the burden of responsibility from health care provider to consumer (patient). That means: - The way it is presented by the health care provider will play a major role in whether the man opts for the PSA test or rejects it. - The men are being asked to decide without real knowledge unless they can independently study the available literature and interpret all the various studies accurately - an unlikely possibility. We should not be shifting the responsibility for recommending or not recommending PSA screening to consumers because of our own uncertainties. We are the experts. Either we have the evidence to recommend it or we do not.
Healthful Life will not recommend PSA testing until there is clear evidence it saves lives or significantly prolongs good quality life. That means we will all have to be patient until definitive results are available - and that will be two to seven years from now. Barry, M.J. Prostate-specific antigen testing for early diagnosis of prostate cancer. The New England Journal of Medicine. Vol 344 (May 3) Pgs 1373 -1377. 2001. |
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