I want to change pace a little today and instead of directly discussing advanced prostate cancer, I am going to discuss an issue that has been coming up in our community, universal prostate cancer screening.

We have all been embattled in an on going dispute, a disagreement about the value of general prostate cancer screening. Some people argue against the need for prostate cancer screening as it causes men who are not in need of treatment to go out and get treatment (over treatment).

We all acknowledge that current treatment modalities often cause significant compromises in the quality of life (QOL) after treatment for both the survivor and his family. Therefore, the over treatment causes many men and their families to suffer the deleterious and unnecessary diminution of their quality of life.

We also hear that “men die with prostate cancer, not of prostate cancer.” True, many men do die of causes other than prostate cancer, even if they have prostate cancer. We also hear that at autopsy many older men will have some prostate cancer in their prostate gland.

Both of these statements are correct, but neither provides a reasonable rationale for not standardizing regular prostate cancer screening (PSA and DRE followed by a biopsy if needed) program for all men over 45 years.

The issue of the QOL effects caused by over treatment is the most commonly cited reason to end general prostate cancer screening. The logic is that without detection there would not be the over treatment we currently experience. Here lies the flaw in the logic, the issue of over treatment which should not be confused with the screening.

The true problem is that men are not properly guided after diagnosis. Many men are not offered and so do not consider all their treatment options. Knowing that you have prostate cancer should not automatically mean that you should undergo invasive prostate cancer treatment. The treatment modality like Active Surveillance (Watchful Waiting) is often a legitimate treatment for men to decide to follow. Men are too often over treated with invasive treatment modalities because of poor medical advice or because they are not properly educated about what options are available.

At the recent survivor research conference I attended, a poster presentation of a prospective study spoke right to this issue. “Prostate Cancer Survivors Treatment Choices: The Family and Cancer Therapy SelectionStudy (FACTS).” The study was funded through the Centers for Disease Control and Prevention and the National Cancer Institute (NCI). The lead author wasd Ingrid J. Hall Ph.D., MPH. The summary points of the poster were:

Although 62% of men had low grade, localized prostate cancer:
a)- 78% considered only one treatment option.
b)- 73% of patients & 68% of family members considered surgery
c)- Only 14% of patients and 4% of family members considered active
surveillance.
d)- Few physicians appear to recommend active surveillance.
e)- Patients and family members were most likely to get information from
treating physicians.
f)- Men who were married and younger were most likely to consider
surgery only.

The data clearly demonstrates that men are either misguided or never completely educated about what options actually exist for the treatment of their cancer.

The commonly cited “myth” of prostate cancer about the presence of prostate cancer in autopsies is also not relevant to the screening controversy. The type of prostate cancer found at autopsy is not histologically comparable to the type of prostate cancer that progresses and eventually kills men, 28,000 this year alone in the United States . (Villers A, et al Prog Urol.1997 Sep;7(4):655-61. Review. French.) and (Sakr WA, et al, The Frequency of Carcinoma and…. J Urol. 1993 Aug(150(2 Pt 1):379-85)

If you are interested in further research into this topic, I urge you to read the very best discussion I have seen written by Ralph Valle. It can be seen at: TO SCREEN

Joel T Nowak MA, MSW