Prostate cancer screening is complicated, mostly still unwise

The United States Preventative Services Task Force (USPSTF) just updated its 2012 recommendation against routine screening for prostate cancer. Previously the USPSTF recommended against routine screening because of the high risk of false positive results that resulted in potentially dangerous medical medical procedures with some gnarly complications.

If you find the word “cancer” incredibly anxiety-provoking, or the thought of an elevated PSA (prostate-specific antigen) test drives you crazy, please: stand up right now, wave your arms in the air, run around in circles, and  yell “cancer” over and over until it’s out of your system. I’ll wait.

Thanks! The new USPSTF recommendation is almost the same as the old one, except for two things. First, new evidence suggests that PSA screening can prevent three cancer deaths per 1,000 men screened. Before, there was no good evidence a PSA test helped anyone. The false-positive rate is still high, and the risk of complications from treatment is still substantial. Second, there’s a new way to approach men who have a slightly positive result or when a low-risk cancer is discovered: active surveillance. This means that so long as you get regular PSA tests, rectal exams, and prostate biopsies, the urologist can keep an eye on your prostate and mostly keep the cancer from spreading. This approach largely keeps prostate cancer from killing you.

It’s almost certain that everyone gets cancer from time to time. Our immune system recognizes it’s present and eliminates it or keeps it under control. For example, if you meticulously examine the prostates of a hundred 65-year-old men who died of causes not related to their prostate, fully half have prostate cancer that never made them ill. Your body just takes care of it. Conversely, it’s difficult to screen for the most dangerous cancers, because they proceed from undetectable to deadly in a matter of weeks or months, way too fast for screening to take place.

So the USPSTF current recommendations are as follows. Most men should not get PSA screening for prostate cancer. If you’re age 70 or older, it’s definitely not recommended. However, in certain high-risk situations or if you request it, your primary physician should discuss the pros and cons.

If you screen and the PSA is normal, you’re all set and there’s nothing more to do. If the PSA is abnormal, then you may want to have a prostate biopsy to find out what’s going on. If the biopsy is normal, you just have inflammation or an enlarged prostate, and there’s nothing more to do. (This is the most common outcome.) If low-grade cancer is present, you should begin active surveillance. (Do not have your prostate removed, because the risk of complications is higher than the risk from the cancer.) A more serious cancer requires more aggressive treatment.

The best nontechnical summary of this issue is on Ars Technica. You can read the USPSTF statement here. The accompanying editorial is extremely useful. And a brief patient summary is here.