Prostate cancer screening: Not a straightforward decision
9/7/2023 by John Matulis, III, D.O., M.P.H.
In some men, prostate cancer can be dangerous. However, most prostate cancers are slow-growing and will not cause any problems.
An autopsy study of men in their 70s who died from non-prostate cancer causes showed that 70% of these men had prostate cancer and were unaware of it. Unfortunately, determining whether a man has a slow-growing cancer that will not cause any problems or a dangerous cancer that should be treated early is difficult.
Until one of the dangerous cancers is in an advanced stage, there are usually no symptoms to indicate a man has the harmful type of cancer. Changes in urination, which are common with aging, are not a sign of prostate cancer, and these changes generally should not influence the decision to undergo prostate cancer screening.
Prostate-specific antigen, or PSA, blood testing is the only recommended test for prostate cancer screening. Men are screened with a PSA test for prostate cancer in the hopes of catching the small number of these bad cancers, which left untreated can shorten a man's life. However, this screening also catches many slow-growing cancers never destined to cause harm in addition to those fast-growing and dangerous cancers. Over the last 10 years, fewer men have been screened and fewer new cases of prostate cancer have been detected; however, the rates of prostate cancer death have remained stable.
Why not screen everybody?
Harm can arise from a simple blood test. A false positive — elevation but not due to prostate cancer — can cause significant anxiety, unnecessary prostate biopsies and repeat testing. Finding a slow-growing cancer that is never destined to hurt you can result in unhelpful treatment. Prostate cancer treatment can result in long-term urinary incontinence, erectile dysfunction and bowel difficulties. Because of the high rate of incidental slow-growing cancer, it's recommended that many men over 70 not receive PSA testing.
What should you do?
If you're a man under 70, you should discuss screening benefits and risks with your primary care clinician. When to start screening may depend on ethnicity and family history. Your primary care clinician will discuss your preferences and values, and together you should decide whether PSA screening makes sense. There is no right or wrong answer. When deciding, be sure to discuss the potential benefits and harm with your healthcare clinician.
Many men experience harm from the screening, including:
- False positive results that require additional testing and possible prostate biopsy.
- Overdiagnosis, including finding a prostate cancer that would never harm you.
- Treatment complications, such as incontinence and erectile dysfunction.
You should also consider your values and preferences, as well as any risks for prostate cancer based on family history, race and ethnicity, or other medical conditions.
If you do decide to be screened and your PSA is elevated, a prostate biopsy is likely to be recommended. While a biopsy sometimes provides an answer, sometimes it doesn't. This cycle of testing, often without clear answers, can cause a lot of frustration and anxiety. Plus, the tests may cause complications or discomfort.
Shared decision making
Patients should make the decision about prostate cancer screening based on the information and perspectives shared by their primary care clinician. This is called shared decision-making and there isn't one answer that is right for everyone. You should take the time to learn all you can about the risks and benefits. Together with your clinician, you can come to a decision that you're comfortable with.
John Matulis, III, D.O., M.P.H., is a physician in Community Internal Medicine, Geriatrics and Palliative Care in Rochester. In addition to general internal medicine, he's board-certified in preventive medicine and has an interest in quality improvement.