Prostate cancer screening: Not a straightforward decision
9/13/2021 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 not destined to cause any problem.
An autopsy study of men in their 70s who died from nonprostate 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 not destined to cause any problems or a dangerous cancer is really difficult.
Until one of the bad cancers is advanced, there are usually no symptoms to indicate a man has the dangerous 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.
Why not screen everybody?
Harm can arise from a simple blood test. A false positive test — 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 than 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 provider. When to start screening may depend on ethnicity and family history. Your primary care provider will discuss your preferences and values, and together you should decide whether PSA screening makes sense.
If you're 55 to 69, the decision to undergo a PSA test for prostate cancer is up to you and your health care provider. There is no right or wrong answer. When deciding, be sure to discuss the potential benefits and harm with your health care provider.
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, you'll probably have a biopsy. 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.
These uncertainties complicate the decision to get a PSA test. 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 provider, 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 in Rochester. In addition to general internal medicine, he's board-certified in preventive medicine and has an interest in quality improvement.