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Is there a big drop in prostate cancer treatment, or just a drop in screening?

Since it’s development in 1984, the Prostate Specific Antigen (PSA) blood test has revolutionized diagnosis, treatment, and follow-up for prostate cancer patients. The PSA blood test measures an enzyme produced in the prostate gland that can provide a marker of possible prostate cancer.  With the availability of PSA testing, the incidence of advanced-stage prostate cancer decreased markedly, and by 2011, the U.S. saw an all-time low in prostate cancer deaths.

Change in Task Force screening recommendations

However, the U.S. Preventative Services Task Force (USPSTF)  suggested that PSA testing could lead to unnecessary biopsies and treatment of insignificant cancers.  The volunteer panel of experts revised its prostate cancer screening recommendations twice, advising against routine PSA testing for older men in 2008, and for all men in 2012.  The revised USPSTF guidelines have resulted in fewer men being offered periodic PSA—and digital rectal examination (DRE)— even at annual physicals.

How reduced screening affects men

Data is now emerging about the possible effects of USPSTF’s revised guidelines.  With the substantial decline in PSA screening across all age groups, the overall rates of prostate biopsy and prostate cancer incidence (the number of men diagnosed) have also decreased.

Yet, with less screening, there has been a significant rise in the rate of men who are now requiring treatment for more advanced prostate cancers, men who missed early stage detection and treatment.  This phenomenon has also been observed at Chicago Prostate Cancer Center (CPCC).

A recent review of the impact of the change in screening guidelines suggests critical misinterpretations of the evidence base regarding benefits and harms of PSA screening.  The authors call for more long-term followup and “smarter screening”, rather than either “screen all” or “screen none” decisions.  Of special concern are younger men who benefit the most from early detection and treatment, since early onset prostate cancer is more likely to be aggressive and fast growing.

Other researchers have demonstrated it was indeed policy changes that decreased screening, rather than changes in practice patterns among specialists.   In other words, men who receive screening and are diagnosed with prostate cancer are being treated as usual.  The authors concluded that between 2007 and 2012, the sharp decline seen in prostate cancer treatment was due in large part to prostate cancers going undetected—and therefore not being treated— due to lack of screening.

CPCC endorses smart screening

CPCC also maintains that timely prostate cancer screening  continues to be important to identify carcinomas before they have time to advance in stage, or metastasize outside of the prostate to other body organs, becoming more difficult to treat.

At CPCC, screening includes both PSA and digital rectal examination (DRE), which can uncover abnormalities associated with prostate cancer even with a normal PSA level.  DRE has the hidden benefit of uncovering clinically significant rectal tumors.  Colorectal cancer represents 8% of all new cancers, which are also more successfully treated if detected at an early stage.

Screening and diagnosis

Both PSA and DRE are considered along with a man’s family history, race, age, and lifestyle, to help determine the need to monitor PSA over time or to obtain a biopsy sample of the prostate gland to definitively test for cancerous cells.  A combination of factors may point to further, genomic testing of biopsy tissue to help determine the likelihood that a cancer will advance in stage.

Advocating prostate cancer screening, CPCC provides clinical staff for an annual free screening event  hosted with Prostate Cancer Foundation of Chicago (PCFC).  The event typically serves over 60 men, as part of CPCC efforts to work hand-in-hand with PCFC for community outreach, patient support, research and education efforts.

For more information on prostate cancer and treatment, or to schedule a consultation, contact CPCC at 630-654-2515.

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