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Revise the report on prostate screening
As published on Newsobserver.com November 17, 2011
RALEIGH -- Last month the U.S. Preventive Services Task Force released a draft report recommending against prostate cancer screening with the PSA blood test. The task force evaluated the benefit from PSA screening and the potential complications that arise from screening-related procedures and the treatment of men who are at low risk of harm from their cancer. Financial costs were not included in the analysis.
The group has asked an important question, but its conclusions are flawed. Perhaps because no member of the task force is involved in prostate cancer care, it inaccurately assessed the impact of PSA (prostate-specific antigen) screening, overstated the risk of cancer treatment and ignored the role for counseling and risk assessment.
One in six American men will be diagnosed with prostate cancer and 3 percent of men will die from it. An estimated 994 men will die from prostate cancer in our state this year according to the N.C. Central Cancer Registry. Several counties in North Carolina have among the highest rate of death due to prostate cancer in the world, and the risk of death from prostate cancer is three times higher in African-American men than in white men.
In order to save lives and reduce suffering this cancer needs to be detected before symptoms occur. The task force reviewed several studies and concluded that the benefit of PSA screening was minimal. Ignored by the report is that prostate cancer mortality had been rising annually until it peaked in 1994 and has subsequently fallen roughly 40 percent. No other change has been made to the "usual care" of prostate cancer during this period except the introduction and incorporation of PSA screening.
Most physicians who treat men with prostate cancer attribute this reduction to PSA screening. There are few victories in the war on cancer - certainly this dramatic result is worth considering.
Most men with prostate cancer suffer no harm from the disease and do not need treatment. Although the treatment is better than described by the task force, there are potential complications. The holy grail of prostate cancer, therefore, is to identify which men with cancer need treatment.
Men diagnosed with prostate cancer can be "triaged" into different high- or low-risk groups and counseled accordingly. I spend over an hour with each newly diagnosed man explaining his risk and identifying his potential treatment options, including surveillance.
Over the last decade the concept of surveying rather than treating young healthy men with low risk cancer has become accepted. The National Cancer Center Network, an organization of experts that provide cancer care, recommends PSA screening and that men with low risk cancer strongly consider surveillance rather than treatment.
The task force report assumes that all men with prostate cancer are treated and therefore the majority are treated unnecessarily. In reality, men with low risk cancer are encouraged to consider non-treatment - with a goal of treating not all men with prostate cancer but only those men whose lives are at risk. Current research is focused on how to better identify this at risk group.
Some men with low-risk prostate cancer will die from their disease. Some men with low-risk cancer therefore elect definitive treatment. As a physician my job is to educate the patient and his family on his cancer and to make him understand the risks and benefits of different options. Each man then has to decide whether he wants to watch his cancer or treat it, and if he wants to treat it, by what means (each has its own risks and benefits).
Some men with low-risk disease choose treatment and some men with higher risk disease do not. The task force does not recognize the ability of a man to decide for himself, according to his own quality-of-life values, if the potential benefit of treatment outweighs the risk. Instead the group has made that calculation for us and compromised patient autonomy.
The PSA blood test saves lives, and when combined with adequate patient counseling and state-of-the-art treatment, men with prostate cancer can lead happy and healthy lives whether they receive treatment or not.
I hope the draft report is revised prior to its acceptance, as was a recent report from the task force on mammograms and breast cancer screening. More importantly, I hope that our physicians continue to offer appropriate screening and that the men in our community continue their participation. If you had prostate cancer wouldn't you want to know, and have the opportunity to decide if you wanted treatment?
Mark Jalkut, M.D., is a Raleigh urologist who specializes in prostate cancer. Click here to read the article on the Newsobserver.com website.
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