Why has screening for prostate cancer become controversial?

The inability to predict what early stage prostate cancer will do makes the “cure,” in many cases, worse than the disease. Many early stage prostate cancers cause no discernable harm if left alone.

Researchers from the famous Karolinska Institute in Sweden reported in the British Medical Journal on their long-term results of screening men for prostate cancer. Almost 1500 men between ages 50-69 were chosen randomly from the general population in the city of Norrkoping  for prostate cancer screening once every 3 years in 1987, 1990, 1993, and 1996 and compared with unscreened men. Lead author Dr. Sandblom and colleagues found no significant difference in death rates from prostate cancer between the screened and unscreened groups.

Unfortunately, the controversy over PSA testing in the U.S. will continue despite the results of this major study. The Swedish men who underwent screening had only a digital rectal exam (DRE) for the first two screenings in 1987 and 1990. The PSA test was added only for the last two screenings. Thus, the study is really a mixed test of both the DRE and, to lesser extent, the PSA test. The practice of testing every 3 years in this study also differs from the standard annual testing that most men would be offered in the U.S. Lastly, PSA testing has arguably improved quite a bit since its widespread introduction in the early 1990s. Each of these issues individually are fairly minor. However, when taken in combination, they give pause for thought before extrapolating these results to current U.S. practice.

Currently, the American Cancer Society recommends that medical providers have frank discussions with their patients about the pros and cons of prostate cancer screening. Potential harms include increased anxiety and discomfort or pain from “unwarranted” negative biopsies at the urologist’s office. Patients need to make informed decisions that fit their own circumstances. They also must be made aware that prostate cancer is a spectrum of disease. Many patients with low-risk disease will “die with it rather than of it,” while other men will receive aggressive screening and treatment for high-risk disease and die despite all of it. Selecting the correct group of men in between that might benefit from prostate cancer screening and treatment is the hard part.

In my opinion, it’s highly doubtful that prostate cancer screening including PSA testing will decrease any time soon in the U.S. The mindset of most Americans, both doctors and patients, will need to be rewired somehow. Men will need to be comfortable and know when to tell their physician: “Doc, don’t just do something. Stand there.”