If you’ve been reading or watching the news lately, you probably saw the headlines about the government’s new recommendations for prostate cancer screening. But are these really new and are they really that different from before? Here is everything you need to know about what is actually going on.
First, a little background.
Prostate cancer screening with a PSA test has been a controversial topic since the test was first approved by the FDA in the 1990s. It was in the news not that long ago when Ben Stiller announced his battle with prostate cancer, and I wrote about it then as well.
The prostate specific antigen (or PSA) test is a blood test that looks for a protein made by prostate cells. If the levels are high, that means that something could be going on in the prostate that causes this protein to leak out into the blood. It could be cancer but also can be the result of a benign condition like inflammation or prostate enlargement. The trouble is that the test can’t tell you the difference between inflammation and cancer, and it also can’t tell the difference between a cancer that will never cause any harm and one that will.
Yesterday the U.S. Preventive Services Task Force, the government-sponsored panel of independent clinicians that reviews and issues recommendations on screening tests, put out a new set of draft recommendations on the PSA screening test that they are seeking public comment on. There are likely to be a lot of comments, as a result the actual final recommendations probably won’t be made for quite awhile. So doctors and societies who choose to use the task force recommendations won’t be changing their practices yet.
So what’s the main difference between these draft guidelines and the previous guidelines issued in 2012? In the 2012 guidelines, the task force recommended against the PSA test for all men. In the new draft, the task force is proposing that men 55 to 69 years of age, regardless of risk factors (like family history), have a discussion about the risks and benefits of prostate cancer screening with their physician and make a personal decision based on the risks and benefits. For men 70 and up, the task force still proposes that they not get the PSA test. This would essentially bring the task force recommendations in line with those of the Urological Association of America and the American Cancer Society, who both recommend against routine screening but do recommend discussing the risks and benefits of the test.
So why is the task force proposing this change now? Well, previously the task force was against screening because the data suggested that the risks outweighed the benefits. Specifically, according to the task force in 2012: For every 1,000 people screened, we will save up to one life — that’s a good thing — but among those 1,000 people, 30 to 40 will develop erectile dysfunction or urinary incontinence, two will have a heart attack, and one will develop a serious blood clot due to treatment. For every 3,000 that are screened, one man will also die from a complication of the surgery.
Now, based on the most recent studies — including a big study from Europe, which showed a benefit to screening — (studies in the U.S. have not shown a benefit) — the task force has revised the numbers. Now they say that for every 1,000 people screened they will save an extra life for a total of about one to two, which is good, but sti, l there are very significant risks of screening.
According to the task force now, for every 1,000 men screened, about 240 will get a positive result followed by a biopsy; unfortunately, many of these will be false positives, and biopsies can have side effects, like pain, bleeding, and infection as well as psychological distress. Of the 240 men with a positive result on the PSA test, 100 will have a positive biopsy, but somewhere between 20 to 50 percent of these men will have a cancer that would never harm them. Since the test can’t tell the difference between a harmful cancer and one that won’t harm you, it is pretty difficult for most men to do nothing, so about 80 of the 100 will have surgery or radiation, which will lead to three men avoiding metastatic disease and the one to two we mentioned before, who will avoid death from the cancer. At the same time, 60 or more men will have a serious complication from intervention like incontinence or sexual dysfunction.
So while it appears that not too much has really changed in the final evaluation, the shift in the proposal from advising clinicians to recommend against the test to discussing it, is a significant shift and is likely to be met with a lot of pushback from physicians who are concerned about the dangers of overscreening. We will have to stay tuned to see what the final recommendations turn out to be.
So what should you do now?
First, don’t think that the draft guideline, whether it’s finalized or not, is a recommendation to get the test. Everyone agrees that there are serious risks to PSA screening and you need to be fully informed about them as well as the benefits before deciding what to do. Getting the test can give you some information, but you have to know how to use it. Everyone will react differently to the information, so deciding if you are going to have the test is a very personal decision. If you are concerned about prostate cancer, talk with your doctor and together you can decide what the best decision is for you.
If you do decide to get a PSA test, and the results are elevated, your doctor may want to do further testing. Remember, an elevated PSA doesn’t necessarily mean that you have aggressive prostate cancer, and you want to discuss all of the risk and benefits of next steps. If it turns out you do have prostate cancer, first don’t panic. Prostate cancer is typically a very slow-growing tumor. One of the other issues with prostate cancer that is important to realize is that while it is pretty common — 13 percent of men get it — most don’t die from it.
In September, a study published in the New England Journal of Medicine found that there was no significant difference in mortality among men with prostate cancer who had either had surgery, radiation, or had only been monitored with no intervention. While disease was slightly more likely to progress in men who were simply followed, the researcher found that they would have to operate on 30 men to prevent one man from having metastatic disease after 10 years. So active surveillance can be an excellent option to discuss with your doctor.
What can you do to reduce the risk of prostate cancer?
There are a lot of studies looking at how to reduce prostate cancer risk and some of the best data is around lifestyle.
The best things you can do to reduce your risk are:
- Eat more fruits and vegetables
- Eat less meat and dairy
- Eat foods rich in omega-3s
- Eat whole grains
- Eat less refined carbohydrates
- Exercise: Shoot for 150 minutes weekly