Yesterday the US Preventive Services Task Force released information that it will recommend against routine PSA testing for prostate cancer. Predictably, there has been a firestorm of responses, mostly criticizing this finding. The most vocal critics are prostate cancer patients and advocates, including their physicians. As a physician who has cared for several thousand prostate cancer patients and a member of this community, I think it is appropriate to chime in. However, what I am about to say will not set well with many. Here is an inconvenient truth: If you live long enough, you will probably develop prostate cancer. 55% of men in their 50’s and 64% of men in their 70’s have prostate cancer when their prostates are carefully examined at autopsy. And the frequency goes up from there. These men are the silent majority – the ones who had no treatment, remained continent and potent in many cases, did not have the anxiety of knowing they had cancer, and lived a full life, dying from some other cause. In fact, prostate cancer accounts for only 4% of all deaths in men. The patients who have been diagnosed and successfully treated ALL feel that prostate cancer screening saved their lives. Most of us who treat prostate cancer or participate in screening for it would like to believe the same thing. Indeed there are some retrospective studies like the famed Tyrol, Austria study that would make us believe that prostate cancer screening is having a major effect. And yet, as I previously blogged on screening, randomized trials suggest that if we save lives at all, …1) It is only in men under 65 and 2) you have to screen and treat a very large number of men (with all those side effects), to save even one life. This controversy will not go away soon, and we all await the day when molecular testing can tell us which cancers we can safely ignore, even if we find them “by accident” on screening. Until then, I think it is perfectly reasonable to salute all of our men who have lived into their 70’s and 80’s, especially those 50% walking about who have prostate cancer and don’t know it and will never miss nor be harmed by NOT being treated or screened. They are the silent majority in this debate.
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The silent majority
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