Screening for Prostate Cancer – Yet Again

It seems to be impossible to drive a stake through the heart of this issue. The current New England Journal of Medicine has two more studies and an editorial on the subject. One (Mortality Results from a Randomized Prostate-Cancer Screening Trial) concludes “that prostate-cancer screening provided no reduction in death rates at 7 years and that no indication of a benefit appeared with 67% of the subjects having completed 10 years of follow-up. Thus, our results support the validity of the recent recommendations of the U.S. Preventive Services Task Force, especially against screening all men over the age of 75 years.”

The second (Screening and Prostate-Cancer Mortality in a Randomized European Study) “that PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis…Overdiagnosis and overtreatment are probably the most important adverse effects of prostate-cancer screening and are vastly more common than in screening for breast, colorectal, or cervical cancer.”

The editorialist, Michael J Barry from the Mass General sums up – “After digesting these reports, where do we stand regarding the PSA controversy? Serial PSA screening has at best a modest effect on prostate-cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective but whether it does more good than harm. For this reason, comparisons of the European Randomized Study of Screening for Prostate Cancer (ERSPC) estimates of the effectiveness of PSA screening with, for example, the similarly modest effectiveness of breast-cancer screening cannot be made without simultaneously appreciating the much higher risks of overdiagnosis and overtreatment associated with PSA screening.”

I’ve covered this subject in great detail in previous posts. Put “Prostate Cancer” without the quotes into the search box at the right and the posts will appear. These new studies just reemphasize that PSA screening for prostate cancer should not be routine. If you are between the ages of 50 and 70 discuss the issue with your physician before electing to have the test. If he’s not up to speed on the subject, and many primary care doctors are not, find someone who is. If you’re over 70 the test is virtually sure to be useless or worse.

Dr Barry notes that “The report on the ERSPC trial appropriately notes that 1410 men would need to be offered screening and an additional 48 would need to be treated to prevent one prostate-cancer death during a 10-year period.” The treatment of prostate cancer carries formidable side effects. Among them are impotence, incontinence, and radiation-induced bowel injury. Think before you screen.

I love to say I told you so, but I’ve been pointing out the problems associated with prostate cancer screening for about 25 years. This screening is not like that for breast or colon cancer. Physicians like to prattle on about evidence based medicine, but only in the abstract. When it comes to practice they throw it out the office window. We should send more of them to Congress where they’d fit in perfectly.