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Prostate Cancer Awareness

October 02, 2012

To Screen or Not To Screen? Ask Your Doctor the Question!

According to the American Cancer Society (ACS), prostate cancer is the second leading cause of cancer deaths among men in the United States. As with most cancers, treatments for prostate cancer are most effective if the cancer is detected in an early stage.

Because early prostate cancer generally causes no symptoms, regular prostate screenings have long been considered an important diagnostic tool. Such screenings generally include a digital rectal exam (DRE) and a blood test to measure the level of prostate specific antigen (PSA) - a protein made by prostate cells.

A controversy over prostate screenings erupted this year, however, when the U.S. Preventive Services Task Force (USPSTF) released its final recommendations in May against PSA-based screenings for prostate cancer and discouraged the use of the test.

"The recommendations of the task force are not the position of the American Urological Association," says Dr. Mark Saleh, a urologist on the medical staff at Washington Hospital. Urologists are the specialists who diagnose and treat the majority of prostate cancers in the U.S.

"We believe that PSA screening can still be a valuable tool in diagnosing prostate cancer, especially because there usually are no symptoms of early-stage prostate cancer," Dr. Saleh explains. "Advanced prostate cancer that has metastasized and spread to other parts of the body can produce severe obstructive symptoms. We rarely see those symptoms now because screenings have been so successful in detecting prostate cancer."

In response to the USPSTF recommendation, the American Urological Association (AUA) issued a press release that stated, in part:

"The American Urological Association is outraged at the USPSTF's failure to amend its recommendations on prostate cancer testing to more adequately reflect the benefits of the prostate-specific antigen (PSA) test in the diagnosis of prostate cancer. It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African American men. Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so. There is strong evidence that PSA testing saves lives."

The AUA also noted that the specialty of urology is not represented in the USPSTF, as there is no urologist on the task force.

"The decision to have PSA screenings is one that a man should make with his doctor after a careful discussion of the benefits and risks of screening," says Dr. Saleh. "Annual PSA screenings for men who wish to be screened generally begin at age 50 for most patients, or at age 40 for men who are at a higher risk for prostate cancer including African Americans and men who have a first-degree relative - a father, brother or son - who was diagnosed with prostate cancer before age 65. Combining a PSA test with a digital rectal exam improves the overall rate of prostate cancer detection."

The ACS and the American Society of Clinical Oncology agree with the AUA position that men should have a chance to make informed decisions in consultation with their doctors about whether to be screened for prostate cancer.

"I always have a frank discussion with my patients about the pros and cons of screenings," Dr. Saleh notes. "There may be some patients for whom prostate cancer screenings would not necessarily be beneficial, such as a man over age 75 who has a life expectance of less than 10 years due to other health conditions. Prostate cancer in men under age 65 tends to be more aggressive than tumors in older men."

Dr. Saleh notes that if a patient's PSA is high and remains elevated, or if the DRE detects any swelling nodules or lumps in the prostate, a biopsy would be needed to determine if cancer is present.

"Today we generally perform minimally invasive needle biopsies to diagnose prostate cancer, and we always take care to reduce the risk of post-biopsy infection or inflammation," he says. "Complications from biopsy procedures are extremely rare, and they certainly are less onerous than the complications of late-stage prostate cancer."

Treatment options for prostate cancer depend on the patient's age, how aggressive the tumor is, and the patient's personal preference.

"For older men and for younger men with low-grade early stage tumors, the most likely recommendation would be to actively monitor the cancer's progress with more frequent regular screenings and repeated biopsies as indicated," Dr. Saleh explains. "Hormone therapy to stop the production of testosterone, which promotes cancer growth, might also be considered to relieve symptoms and slow the growth of tumors."

For younger men with more aggressive prostate cancers, radiation therapy might be appropriate in the form of external beam radiation therapy or brachytherapy - the implantation of radioactive "seeds" into the prostate. For many patients, surgery to remove the prostate is the most effective treatment.

"At Washington Hospital, we have a less-invasive surgical alternative to the traditional open prostatectomy, using the daVinci robotic surgical system that allows us to perform the operation laparoscopically with three or four tiny incisions," Dr. Saleh notes. "The robotic system also magnifies the surgical site, giving the surgeon better visualization. In the right surgeon's hands, the results of laparoscopic surgery - with or without robotics - are as good as open surgery. The patient also experiences less post-operative pain and a quicker recovery. In addition, current surgical techniques allow us to preserve the nerves necessary for erectile function and maintaining urinary continence in the majority of patients."

The bottom line, however, is that prostate cancer treatment options can only be evaluated once a positive diagnosis is made.

"Rather than discouraging nearly all men without symptoms of prostate cancer from having a PSA screening test, we need to encourage men to talk with their doctors and evaluate their prostate cancer risks as well as any risks associated with screening," Dr. Saleh suggests. "Because most early prostate cancers cause no symptoms, the PSA test has been an important diagnostic tool that has allowed us to provide effective treatments before the disease progresses to high-grade metastatic cancer. Men need to make an informed choice about screenings, but it should still be their choice."

For more information about prostate cancer, including recommendations for screening, visit the Web sites of the American Urological Association at www.auanet.org, the American Cancer Society at www.cancer.org, the American Society of Clinical Oncology at www.asco.org, and the U.S. Preventive Services Task Force at www.uspreventiveservicestaskforce.org.