The Screening Conundrum

I have the honor of giving quite a few talks to prostate cancer support groups during the year, and one thing I have noticed is how adamant most of the men are about the value of screening. Many of them have started websites or mailing lists that tell men “you need to know your psa” or “get screened to save your life” or other similar messages. I can appreciate this point of view. I don’t think any man who has been diagnosed with prostate cancer and has gone through some sort of treatment has any real choice but to look at his experience in one of two ways: If he has been cured by an aggressive procedure, he considers himself “lucky” to have been “caught in time”. This is a very rational point of view, and it is even more important to feel this way if the treatment has produced undesirable side effects like incontinence or impotence. Why would any man want to put up with those conditions if there wasn’t a very valid reason behind the decision that led to the condition? The other way men often look at their situation (if they now have rising PSA in spite of treatment or worse, outright metastases) is “if only I had been screened and my cancer detected earlier, I wouldn’t be in this situation”.

I have great empathy for each of these views. I am sure I would feel the same way. However, they illustrate the challenge of the individual versus the “herd” in considering screening. Although there are valid criticisms of the two largest studies, the PLCO and the ERSPC trials, one has to admit that we all wish screening was much more effective. The editorial that accompanied the original reports is worth reading if you have strong feelings about this issue. It’s title is “The Controversy That Refuses to Die”. Here is one of the most succinct statements from that editorial: “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.” Thus, all of the men in the support groups and other supporters of more screening really don’t take into account the enormous burden of overtreatment. Remember, at least 80% of 90 year old men have prostate cancer when you slice up their prostate carefully after they die of something else. Many of the cases being found by more screening are these guys who would have had the same life, no side effects of treatment, and no worries about “having cancer” if they had never been screened.

I would like to suggest at least one place where we could perhaps agree that screening should NOT be done and maybe ask the readers of this blog how to get this message out. In this month’s JCO, there is a study showing that among men 70 years and older, 31% of those with low life expectancies were still being screened. This seems really unkind. How can we justify taking our most debilitated older men and add the burden of a cancer diagnosis to their situation? Indeed, the same study found that screening rates were only 24% among men aged 50-54 and didn’t peak until it reached 45% among age 70-74. There are many studies that have found no improvement in life expectancy is achieved by treating men over age 65 for prostate cancer. Why are we doing this? I would suggest that it is because there is inadequate information being given to the potential screen subjects, and that hospitals and physicians alike are “trained” to screen all comers. Worse, recently published studies have found that when a hospital purchases a robot, men in the region are more likely to have surgery for prostate cancer. And of course, we don’t even want to go into the controversy that has come up surrounding the purchase of radiation therapy equipment by urology groups who wish to add IMRT to their treatment portfolio. Financial incentives are a poor way to make decisions about medical care in my view.

So, when it comes to screening for prostate cancer, my own thought is “be VERY sure you know what you are getting into”. I am personally getting screened at present, but in the not too distant future (maybe when I turn 70 or so), I’m going to drop out of this practice and take my chances. I hope other physicians will do the same and take the time to explain to their patients why they are taking that course. At some point, the “cure” may be worse than the disease – and each man should have a full understanding of that reality before accepting a “free prostate cancer screening” at his local hospital or health fair.