Prostate cancer: To test or not to test?

The past decade has seen a growing controversy about screening for prostate cancer. Many men ask whether it is appropriate to undergo this testing, which includes a prostate specific antigen blood test and a digital rectal examination of the prostate. Many women have asked whether their spouses should be tested. Why would we not want to screen for a disease that ranks as the most frequently diagnosed non-skin cancer in American men and ranks third in number of cancer-related deaths? After all, we cannot treat prostate cancer if it is not first diagnosed.

According to recent estimates from the American Cancer Society, over 200,000 American men are diagnosed with prostate cancer annually, and over 26,000 men will die from prostate cancer each year. It is estimated that one out of seven American men will develop prostate cancer at some point. The disease typically strikes older men, with the majority over the age of 65 years; however, younger men are frequently diagnosed with the disease as well. So why is screening not an obvious choice for everyone?

A fundamental problem is that the PSA test and DRE are not foolproof measures. A high PSA level does not always mean cancer is present, and a normal or low level may occur in the presence of prostate cancer. Cancers often cannot be felt in the DRE. These tests are, however, the best we have at present.

Another problem is that many prostate cancers progress so slowly that men will live out their years and succumb to something other than prostate cancer. Organizations including the American Society of Clinical Oncology and the American Urological Association counsel against prostate cancer screening for older men not expected to live longer than 10 years. This leaves the question of younger men who are diagnosed with prostate cancer and who might benefit from an early diagnosis. Several studies from North America and Europe identify a cancer survival advantage in men between 50-69 years of age treated for localized prostate cancer. Furthermore, current recommendations support screening men in their 40s if they have a first-degree family relative with prostate cancer, or are African-American.

Yet another relevant issue includes the side effects and “harms” associated with diagnosis and treatment. If a man’s tests reveal abnormalities, a biopsy may be recommended for diagnosis. The biopsy is generally safe but sometimes leads to bleeding or infection. If the biopsy detects cancer and if the patient and physician agree on treatment, there are risks and side effects that may follow prostate surgery or radiation treatments, including urinary control difficulty, loss of erectile function or rectal injury. While recent advances have lowered the impact and duration of these adverse effects, some remain.

Not all men found to have prostate cancer will go on to have treatment at the time of diagnosis. It is widely recognized that small, early cancers that are localized within the prostate gland may progress slowly and can be followed by a strategy of “active surveillance,” with periodic re-examination and repeat biopsies in the future.

Another treatment option is hormone therapy, which can improve certain treatment outcomes or slow the growth of more advanced cancer. Hormone therapy has its own potential side effects including hot flashes, breast enlargement and diminished libido. The aftereffects can result in physical and emotional stress affecting men and their families.

The question of whether to test does not have a universal answer. Age, ethnicity, family history and quality of life should factor into the answer. Before making such an important decision, men would be wise to discuss the matter with their health care providers.

This story was originally published March 10, 2017 at 6:08 PM with the headline "Prostate cancer: To test or not to test?."