ACS Prostate Screening Guidelines
The American Cancer Society’s (ACS) latest pronouncement on prostate cancer screening has them pulling back from their past recommendations. They are no longer recommending yearly PSA and digital rectal examinations (DRE) but instead stressing that the patient should make an informed consent in consultation with his physician.
ACS guideline:
Beginning at age 50, asymptomatic average-risk men with at least a 10-year life expectancy should receive information that allows them to make an informed decision, in collaboration with their healthcare providers, about prostate cancer screening
Despite the clear fact that PSA is the most accurate single cancer detection test in oncology, recent complaints about false positive test results (as occurs with all tests) and an inability to differentiate the most dangerous prostate cancers has the ACS backtracking on its prior pronouncements. The America Urological Association (AUA) and the ACS are no longer in agreement about who should be screened. This is a complex issue that even the experts do not agree, making it even more puzzling that the ACS is abdicating its leadership role and now wants to leave this controversy up to the patient.
Screening technically refers to testing an individual with no signs, symptoms or risk factors for a particular disease. Thus screening recommendations should not be taken to dissuade testing of men with lower urinary tract voiding complaints or a family history of prostate cancer. Most people have had their cancer for many years before it is detected regardless of the type of cancer. A down side of early detection is that a tiny cancer found may never have caused the individual any problem in their lifetime thus subjecting them to unnecessary testing and treatments. We clearly need to do more research in this area to better predict the lethality of a cancer in any specific individual case. Yet we cannot forget that it is early detection, when a cancer is still just a small clump of cells that has allowed us to eradicate the cancer and maintain a person’s functional quality of life. Today we rarely do a true radical prostatectomy anymore. A nerve sparing prostatectomy is better described as a total prostatectomy because we do not take a lot of tissue surrounding the prostate as we did in the past. This allows us to dramatically improve urinary control and erectile function results. It is similar to our experience with breast cancer. Twenty-five years ago a radical mastectomy was the standard of care. Today, because of early detection (mammography and self examination), we are able to successfully eradicate the cancer in many women with a lumpectomy and preserve most of the breast. I believe it is always better to know about the cancer than not. An individual can always op for surveillance and delay treatment if they so desire. Once the cancer is beyond a certain point, cure is limited. However, with careful close monitoring an individual may avoid unnecessary treatment without unnecessary risk of advanced disease.
The ACS guidelines further advise against a DRE. The DRE should remain a routine part of a comprehensive physical examination. Not only can it pick up the 20% of prostate cancers which present with a normal PSA but can help detect rectal carcinomas, hemorrhoids and other anal lesions.