The prostate gland is a small gland that sits near the neck of the bladder in men. At the low point of the torso, it resides just in front of the rectum at the base of the penis. It produces part of the semen fluid and, when enlarged, as it does in half of all men over 50 years old, can cause urinary symptoms of urgency, frequency and possibly interfere with erection or ejaculation.
The risk of death by prostate cancer is 2.5% of all men but remains the second most common cancer in men after lung cancer. More frequent in older men, it can also affect men under the age of 50.
The Centers for Disease Control and Prevention confirms the reputation of prostate cancer as a slow growing tumor. Men are actually likely to die of something else, even when they have prostate cancer. The statistical median age of death from prostate cancer is 80 years old. Nonetheless, we are living to be much older.
With this disease, controversy surrounds the screening and treatment.
For many years, the best screening test for prostate cancer in men, the PSA blood test, has been considered imperfect. Some experts say it is only accurate 60% of the time. Do you really want to depend on a tool that only works six out of 10 times?
If it is still the best option in your toolbox, it is not much of a choice. New information from studies regarding accuracy and outcome published by two expert medical panels in the U.S. have added confusion rather than clarity to the approach for medical screening and treatment.
The expert panels confirm the long-standing concern over the high number of false positive results of the PSA blood test.
Unfortunately, benign enlargement of the gland, so common in aging men, also causes abnormalities in the PSA test. This leads to many unnecessary biopsies and even radical treatment that is unnecessary.
The consensus of experts finds the number of false positives, negative biopsies, and unnecessary invasive treatment unacceptably high when relying on the PSA blood test. Yet many patients and providers finding a positive PSA, feel there is an implied opportunity and need for early intervention even though this is not supported by research.
Historically the PSA test was never meant to be a screening test. It was found to correlate with the presence of cancer after the fact and became a marker that could be followed after treatment to measure resolution of the cancer. It was only later appreciated that benign enlargement of the gland also caused high levels and false positives. These high PSA results could not be readily differentiated from cancer without further invasive biopsy. Serious ramifications of these procedures include financial cost, time loss from work, anxiety, depression, impotence and altered bladder function. Yet doing no screening is equally unacceptable.
A consensus has developed around watchful waiting and observation in men who have a positive PSA test but no clinical symptoms.
Observing over time and repeating the tests over an extended period is more sensible in most, as the disease is a slow motion cancer for the majority of men. Research around this group who have no blood in urine or semen, no urinary symptoms but only a positive PSA, the test was found to be only 25% reliable. Another study found 80% negative biopsies in the group who had only a positive PSA blood test without any other clinical symptoms or risk factors.
The experts agree that men with symptoms of aggressive disease need aggressive treatment. However, the large majority of men being screened fall into the category of no serious symptoms.
They deserve patient observation, reassurance, supportive counseling and clinical monitoring rather than moving quickly to invasive biopsies and treatment.
There may be change coming: Numerous medical centers in the United States and around the world have under development new testing that will either supplement or make the PSA obsolete.
I hope these breakthroughs will bring clarity sooner rather than later. In the mean time, patience and active surveillance with the help of your healthcare provider is the order of the day.
Dr. Bruce Kaler
