The Prostate Dilemma

Posted on July 13, 2009. Filed under: Affordable Health Care, Cancer, Preventive Care, Prostate, Recommended Medical Guidelines | Tags: , , , , , , |

Even the medical community can’t seem to agree about prostate screenings. In March, after a U.S. study suggested that screening for prostate cancer does not reduce death from the disease, a bigger European study suggested that screening can lower the death rate as much as 20 percent. (Both studies were reported in the New England Journal of Medicine.)

Then in April, the American Urological Association issued new guidelines lowering the age recommended for prostate-specific antigen (PSA) screening from 50 to 40 years.

Peter R. Carroll, professor of medicine and chair of the Department of Urology at the University of California, San Francisco, and chair of the AUA guidelines committee on PSA screening, said: “There is no patient for which there is no risk. … The new guidelines not only allow for earlier detection of more curable cancers, but also allow for more efficient, less frequent testing. . . . Evidence shows that the PSA test is more accurate in younger men. …

“The single most important message of this statement is that prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists.” Dr. Carroll said. “There is no single standard that applies to all men, nor should there be at this time, and the AUA does not recommend a single PSA threshold at which a biopsy should be obtained.”

This is a great step forward for those of us who are promoting early detection and treatment of prostate and all other cancers.  The AUA not only urges screening at age 40, bu also cites changes in the PSA of .4 (rather than .75 as before) as a sign of potential prostate cancer and indication for further evaluation.

For a long time, doctors and guidelines have gone with the 50-plus threshold, contending that earlier screenings often result in unnecessary procedures that can be harmful. They also cite the chance of  false positives, which is an initial diagnosis that seems to confirm the disease when it turns out that it’s not cancer. False positives, many claim, cause patients stress. Yet many of us believe that more men will die with this disease than of it.

But these arguments distract from the fact that cancer of the prostate remains the second most common cancer related death in males. Without screening at all, many men will suffer a horrible death and regret not having had the disease detected early just because they were considered statistically insignificant or because medical professionals didn’t want to risk coming up with a false positive.

The good news is that with the simple PSA test and a digital exam, prostate cancer, like most cancers, can be detected early and successfully treated. Treatment consists of removing the prostate and/or radiation; in cases where the cancer is felt to be nonaggressive, the cancer is merely observed. Undoubtedly, any complications from the treatments can be directly attributed to the skill set of the treating physician. Many urologist have very low complication rates.  Unfortunately, the converse is also true.

I can’t say this enough: Early detection is our best position in treating cancers and most other diseases.  We cannot catch a disease like prostate cancer early enough to treat it if we screen only men 50 and older or not at all. As we design new health care strategies we must always keep the following question in mind:  Are we saving money or are we saving lives?

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