Prostate cancer is a major killer and the most common cancer among men. So it's no wonder that a new national recommendation on screening -- or rather, not screening -- for the disease has triggered a stir in the media, confusion among the public and an outcry from patients who credit the test for saving their lives.
Despite the uproar, several physicians said, men shouldn't expect much different when they go for an annual physical, which is when the screening is usually administered, typically to those age 50 or older.
The new recommendation from the U.S. Preventive Services Task Force is that men younger than 75 shouldn't routinely get a type of test called PSA screening. The task force, an independent group of healthcare professionals that crafts disease prevention policies for the federal government, had recommended three years ago that men older than 75 shouldn't get the test.
The test generates a high rate of false positive results, and studies have shown that, while it does help detect more prostate cancers, it doesn't cut the rate of death from the disease.
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Critics say the false positives often lead to unnecessary treatment and surgeries that can harm patients who might well have survived the cancer with little or no problem, as it can often grow slowly for decades without symptoms.
But several family physicians and urologists -- the doctors who form the front line of defense against prostate cancer -- say they and their colleagues greeted the new recommendations with a collective shrug.
They said the test itself does no harm and still has a proper role in screening and informed decision-making about the disease. Screening should also include consideration of family history of prostate cancer, age, symptoms and the results of a standard manual examination of the prostate for irregularities, they say.
"For all the talk, I'm not sure a whole lot has changed," said Dr. Richard Lord, a family physician in Winston-Salem and president of the North Carolina Academy of Family Physicians.
Lord was on a camping trip with a friend who is a urologist just after the panel issued the new recommendation, and both were scratching their heads over the stir.
"My sense is that most doctors were like us: They were wondering what all the fuss was about," he said.
Lord hasn't altered his approach to screening for the disease, nor what he tells patients about PSA screening. He has always given patients a brief talk about the strengths and shortcomings of screening, and will continue to do so, he said.
PSA screening is typically done to men 50 or older during their annual physical. It helps detect prostate cancer by measuring the level of a protein in the blood produced by the prostate. An elevated level can indicate the presence of cancer, but it takes a biopsy of tissue from the prostate to determine the actual presence of cancer.
The task force has never actually recommended PSA screening and basically made minor changes in its recommendations, Lord said. Its prior position had been that it didn't have enough evidence to say whether testing was a good idea.
Its new position for men younger than 75 doesn't address cases of younger men with symptoms that can suggest cancer or with factors such as a family history of the disease, which can greatly increase chances of developing it.
For someone showing potential symptoms, such as decreased or irregular urinary flow or the need to get up often at night to urinate, the PSA test becomes a diagnostic tool rather than a screening method.
And while many prostate cancers are slow-growing and can take decades, others are aggressive and can kill quickly if not diagnosed early.
Dr. Mott Blair, a family doctor in Elizabethtown, N.C., said that although he hasn't changed the substance of what he tells patients about PSA screening, he has used the current furor and complexities of the issue as an opportunity to educate them more on the shortcomings of not just PSA screening but other types of medical tests, too, such as pap smears and mammograms.
Thinking about the individual
Among doctors, a widespread criticism of the task force recommendations is that they might make sense when considered for the entire national population, but not for thoughtful care of a specific individual who may turn out to have an aggressive form of the disease that must be caught early and treated quickly.
Dr. Frank Tortora, a surgeon with Cary Urology in Cary, N.C., said that he has gone to funerals for prostate cancer victims in their 40s, and also has an elderly cancer patient who has outlived two of the doctors who treated him.
Tortora tells patients it is naive to think every case of the cancer is the same, because all progress at different speeds.
The PSA test is useful, he said, particularly when patients have earlier, baseline measurements to compare with the test results. The results then can be used along with other tests such as the manual prostate exam and knowledge about symptoms and family history, to help doctors build a mental picture of what might be going on.
"Is it perfect?" he said. "No. Just to have the blood drawn, and no follow-ups, that's not very helpful. But to have someone who understands the nuances of your case to interpret the PSA, that's important."
About prostate cancer
Cancer of the prostate is rare among men younger than 45. It typically begins to develop among men over 50 and is common among elderly men. About two-thirds of the cases grow slowly, and many men harbor the disease without symptoms or treatment for decades, and die of other causes.
There are fast-growing types, though, that can kill much more quickly, often after spreading to surrounding bone or to the lymph system.
The National Cancer Institute estimates that 240,890 men will be diagnosed with prostate cancer and 33,720 will die of it this year.