Screening men for prostate cancer provides little or no benefit in saving lives and can lead to painful, debilitating and expensive medical...
Screening men for prostate cancer provides little or no benefit in saving lives and can lead to painful, debilitating and expensive medical treatments without any obvious benefit, according to two major studies released Wednesday.
A U.S. study of 76,000 men found no mortality benefit from screening, while a European study of 162,000 men found a marginally significant 20 percent reduction in deaths, according to reports published online Wednesday in the New England Journal of Medicine.
Even with the reduction found in the European trial, it was necessary to screen 1,400 men and treat 48 cancer cases to save one life. “What the European study tells us is that if you are a man who chooses screening, you are 47 times more likely to be harmed by screening than to have your life saved,” said Dr. Otis Brawley, chief medical officer of the American Cancer Society.
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Not worried? Don’t screen
In contrast, only 11 women with breast cancer must be treated to save two lives, he said, and the side effects of treatment can be much less severe. Men can suffer long-term impotence and urinary incontinence, while women can have reconstructive surgery and may suffer fewer permanent effects.
“If a man is really worried about prostate cancer, he should take that statistic under advisement and decide to get screened,” Brawley said. “If he is not worried, he should decide to avoid screening.”
Whether to screen has been controversial for at least 20 years. Many clinicians have believed that finding a tumor early and cutting it out is the best possible way to treat prostate cancer.
Others have argued that many prostate tumors grow so slowly that the patient is likely to die of some other cause before the tumor becomes a threat. These critics argue that treatment can cause more damage than leaving the tumor alone.
Still a doctor-patient decision
The newest findings would seem to support that approach. But doctors and patients are cautious. And definitive as the new results may seem, some experts said they’re not clear-cut enough to recommend against screening for prostate cancer. As such, the decision to screen is likely to remain one made in agreement between doctor and patient.
The bottom line is that they “are not necessarily going to change practice much in the United States,” said Dr. Howard Sandler of Los Angeles’ Cedars-Sinai Medical Center, a spokesman for the American Society of Clinical Oncology.
The papers “don’t tell patients anything different from what we have been telling them,” which is do it only if you are very concerned, added biostatistician Ruth Etzioni of the Fred Hutchinson Cancer Research Center in Seattle. “When you have a large controlled trial like these, it is usually the final word … conclusive. These are very unsatisfying.”
About 186,000 American men will be diagnosed with prostate cancer this year and an estimated 28,660 will die of it.
Screening for the disease usually involves a prostate-specific antigen (PSA) blood test and a digital rectal exam, in which a physician feels the prostate looking for abnormalities.
In the United States, a normal level of PSA is considered to be 4. Higher levels generally indicate the presence of a tumor, and rising levels indicate an aggressive tumor.
Since 1992, five years after the PSA test was introduced, U.S. death rates from prostate cancer have declined about 4 percent a year. Some attributed the decline to the test, while others said it is due to better treatment.
Little in the way of guidelines
No group recommends routine screening. The American Cancer Society and the American Urological Association recommend that men older than 50 simply be offered the testing option if they have a life expectancy of more than 10 years.
The U.S. Preventive Services Task Force, established by Congress to make recommendations about preventive care, issued guidelines last fall stating that men older than 75 should not be given the test. The group said there was not enough evidence of efficacy to produce guidelines for younger men.
The two studies were designed to give a definitive answer about the value of such screening. Both are interim reports, and researchers will continue to follow the subjects.