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Is prostate cancer screening worth it?

Updated on April 14, 2016

Usefulness of cancer screening

Do you believe that routine prostate cancer screening is worth it?

See results

Willingness to get screened

Would you consider prostate cancer screening?

See results

Facts about prostate cancer

  • Approximately 1 in 7 American men will be diagnosed with prostate cancer (http://m.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-key-statistics)
  • Approximately 1 in 38 American men will die of prostate cancer (ibid)
  • Second most common cancer in American men, after skin cancer (ibid)
  • "Among very elderly men dying of other causes, a surprising two-thirds may have prostate cancer that was never diagnosed."
  • Most men diagnosed with prostate cancer will die of other causes
  • Very high survival rate

Risk factors for prostate cancer

  • Disclaimer: Risk factors are conditions that increase the risk of having a certain disease. Having one or more of these conditions does not mean you will get prostate cancer, and having none of them does not mean you will not.
  • Age (over 50)
  • Race (African-American)
  • Family history (first-degree relatives, such as fathers and brothers)
  • Genetic mutations
  • Exposure to Agent Orange
  • High testosterone levels (http://www.cancer.net/cancer-types/prostate-cancer/risk-factors-and-prevention)

Prostate cancer diagnosis

  • PSA (Prostate Specific Antigen) blood test
  • DRE (Digital Rectal Examination)
  • Biopsy
  • None of these tests is particularly reliable (http://www.nhs.uk/Conditions/Cancer-of-the-prostate/Pages/Diagnosis.aspx)

Test statistics

Source

Sensitivity, specificity, positive predictive value, and negative predictive value

Sensitivity: Of all the people that actually have the disease, how many test positive for it?

(A/A+C)*100 (see Chart on the right)


Specificity: Of all the people that don't have the disease, how many test negative for it?

(D/B+D)*100 (ibid)

Positive predictive value: Of all the people who test positive for the disease, how many actually have it?

(A/A+B)*100

Negative predictive value: Of all the people who test negative for the disease, how many actually do not have it?

(D/C+D)*100

For further reference and examples, see :

https://onlinecourses.science.psu.edu/stat507/node/71

PSA Test Statistics

Statistic
PSA cutoff at 4 ng/mL
PSA cutoff at 3ng/mL
Sensitivity
21% for any prostate cancer, 51% for high-grade prostate cancer
32% for any prostate cancer, 68% for high-grade prostate cancer
Specificity
91%
85%
Positive Predictive Value
30%
?
Negative Predictive Value
85%
?
Source:http://www.uptodate.com/contents/screening-for-prostate-cancer?source=outline_link&view=text&anchor=H7597682#H7597682

DRE Test Statistics

Statistic
Percentage
Sensitivity
59%(1)
Specificity
94%(1)
Positive Predictive Value
5-30%(1)
Negative Predictive Value
67%(2)
Sources: (1) http://www.uptodate.com/contents/screening-for-prostate-cancer?source=outline_link&view=text&anchor=H7597682#H7597682(2)http://www.ncbi.nlm.nih.gov/pubmed/23228289

You might benefit from prostate cancer screening if....

  • If you are between the ages of 40 and 75
  • If you are of the "better safe than sorry" mindset
  • If you have a family history of prostate cancer
  • If you are African-American

You might not benefit from prostate cancer screening if...

  • You are under the age of 40, regardless of your risk factors
  • If you prefer to avoid unnecessary pain, anxiety, overdiagnosis, and over treatment for a cancer that may never become a problem
  • If you are over 70 and/or are expected to live less than 10 years

Prostate cancer stages

Localized, cannot be detected by imaging or felt during the DRE. Usually diagnosed during TURP or by needle biopsy (http://www.cancercenter.com/prostate-cancer/stages/), (http://m.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-staging
Localized, cannot be detected by imaging or felt during the DRE. Usually diagnosed during TURP or by needle biopsy (http://www.cancercenter.com/prostate-cancer/stages/), (http://m.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-staging | Source
Prostate cancer Stage IIa: Can be seen and/or felt, localizes to one-half or less of one side.
Prostate cancer Stage IIa: Can be seen and/or felt, localizes to one-half or less of one side. | Source
Prostate cancer Stage IIb: Can be seen and/or felt, localized to more than one-half of one side(http://m.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-staging
Prostate cancer Stage IIb: Can be seen and/or felt, localized to more than one-half of one side(http://m.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-staging | Source
Prostate cancer Stage III: Tumor breaks through the prostate capsule on one side and may ispread to nearby structures, such as seminal vesicles (http://www.cancer.net/cancer-types/prostate-cancer/stages)
Prostate cancer Stage III: Tumor breaks through the prostate capsule on one side and may ispread to nearby structures, such as seminal vesicles (http://www.cancer.net/cancer-types/prostate-cancer/stages) | Source
Prostate cancer Stage IV:Cancer spreads to more distant structures, such as the bladder.
Prostate cancer Stage IV:Cancer spreads to more distant structures, such as the bladder. | Source

Prostate cancer treatment

  • Watchful waiting
  • Active surveillance (wait-and-see)
  • Prostatectomy
  • Chemotherapy
  • Radiation therapy
  • Hormone therapy
  • Transurethral resection of prostate (TURP)
  • Cryotherapy

How is watchful waiting different from active surveillance?

  • Watchful waiting: fewer tests, only intervene if the patient experiences new symptoms
  • Active surveillance: more tests, intervene if test results change (e.g. PSA value increases)
  • Source: http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-watchful-waiting

Am I a candidate for active surveillance?

You might be a candidate for active surveillance if you wish to avoid immediate treatment and:

  • Your cancer is not advanced (Stage T1 or T2a), aggressive, or large in volume ("1/3 of the biopsy is positive and less than 50 percent of any single core involved" (2))
  • Or
  • You have a limited life expectancy
  • Or
  • You suffer from chronic health conditions that might make it more difficult to tolerate surgery, radiation, or chemotherapy
  • And
  • You are willing and able to undergo regular PSA tests, imaging, and biopsies
  • And
  • You had a really good quality biopsy
  • Sources: (1)http://www.pcf.org/site/c.leJRIROrEpH/b.5813295/k.FA2E/Active_Surveillance.htm
  • (2) http://www.ucsfhealth.org/education/interview_carroll_active_surveillance_for_prostate_cancer/

You might be a candidate for watchful waiting if...

  • You are older (over 75) and/or
  • You are unwilling/unable to undergo more frequent tests
  • Your cancer is slow-growing and low-riak (lower than for active surveillance) and/or
  • You would rather avoid treatment or cannot tolerate it and/or
  • Your cancer is localized and asymptomatic, but you cannot/do not wish to undergo treatment or your cancer is advanced/metastatic and asymptomatic
  • Sources: (1)
  • http://www.pcf.org/site/c.leJRIROrEpH/b.9297669/k.8560/Watchful_Waiting_Becoming_More_Common_for_Prostate_Cancer_Patients.htm
  • (2) http://www.webmd.com/a-to-z-guides/news/20150707/watchful-waiting-becoming-more-common-for-prostate-cancer-patients
  • (3) http://urology.ucla.edu/body.cfm?id=246
  • (4) http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/treatment/monitoring-prostate-cancer
  • (5) http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Prostate/Treatmentforearlyprostatecancer/Watchfulwaiting.aspx

You might be a candidate for prostatectomy if...

  • You are younger (under 65)
  • You are otherwise in good health
  • Your cancer is growing rapidly
  • You have a life expectancy of 10 years or more
  • You are more likely to die of prostate cancer left untreated than of old age or other health conditions
  • Your cancer is localized (Stages T1 or T2)
  • Sources:
  • (1). http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/treatment/types/treatment-options-for-prostate-cancer
  • (2) http://www.cancerresearchuk.org/overlays/prostate-cancer-treatment-flow-chart.html
  • (3) http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/treatment/surgery/radical-prostatectomy
  • (4) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-surgery

You might not be a candidate for a prostatectomy if...

  • You are older
  • Your cancer is growing slowly
  • You are in poor health (e.g. heart disease)
  • You are overweight
  • You have a life expectancy of less than 10 years
  • Your cancer has spread
  • You are more likely to die of old age or other health conditions than untreated prostate cancer
  • Sources:
  • (1) http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/treatment/surgery/radical-prostatectomy
  • (2) http://www.cancerresearchuk.org/overlays/prostate-cancer-treatment-flow-chart.html
  • (3) http://prostatecanceruk.org/prostate-information/treatments/surgery

You might be a candidate for chemotherapy if...

  • Your cancer is in later stages and has spread
  • You are otherwise healthy, in order to be able to tolerate side effects
  • You may be offered chemotherapy in earlier stages of cancer as part of a clinical trial
  • Hormone therapy is not working well for you
  • Keep in mind that chemotherapy does not get rid of the cancer, but merely shrinks it and slows down its growth
  • Sources: (1) http://prostatecanceruk.org/prostate-information/treatments/chemotherapy#who-can-have-chemotherapy
  • (2) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-chemotherapy

You might not be a candidate for chemotherapy if...

  • You are in early stages of prostate cancer (exception: clinical trials)
  • You are not healthy enough to tolerate the side effects
  • Your kidney or liver function is impaired
  • Source: http://prostatecanceruk.org/prostate-information/treatments/chemotherapy

You might be a candidate for radiation therapy if...

  • Your prostate cancer is localized, and you are unwilling or unable to undergo a prostatectomy, or simply prefer an easier procedure with a quicker recovery
  • Your cancer persists or comes back after surgery
  • Your cancer has spread to nearby tissues (to be used along with hormonal therapy)
  • Your cancer is advanced (to relieve symptoms)
  • Sources: (1) http://www.healthlinkbc.ca/healthtopics/content.asp?hwid=tc1702
  • (2) http://www.scottdmillermd.com/resource-pages-for-links/choosing-a-treatment-for-prostate-cancer-surgery-versus-radiation/
  • (3) http://prostatecanceruk.org/prostate-information/treatments/surgery
  • (4) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-radiation-therapy

You might not be a candidate for radiation therapy if...

  • External beam radiation therapy: if you have a history of certain bowel disorders, such as ulcerative colitis and diverticular disease
  • Brachytherapy: if you have a history of TURP, frequent or urgent urination, or if your prostate is very large
  • Sources: (1) http://emedicine.medscape.com/article/454283-overview#a2
  • (2) http://www.beaumont.edu/cancer/types-of-cancer/prostate-cancer/prostate-cancer-treatment/radiation-treatment-for-prostate-cancer/brachytherapy-treatment-for-prostate-cancer/

You might be a candidate for hormone therapy if...

  • "If the cancer has spread too far to be cured by surgery or radiation, or if you can’t have these treatments for some other reason" (1)
  • Your tumor is localized, but you are not a candidate for surgery or radiation (1,2)
  • Your cancer is not responding/partially responding to surgery or radiation
  • You are having radiation therapy and need to shrink the tumor first
  • You are having radiation therapy and are at a high risk for recurrence
  • Sources: (1) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-hormone-therapy
  • (2)http://www.cancer.gov/types/prostate/prostate-hormone-therapy-fact-sheet

You might not be a candidate for hormone therapy if...

  • You are in early stages of prostate cancer that can be treated surgically or with radiation therapy
  • You have heart disease or diabetes
  • Sources: (1) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-hormone-therapy
  • (2) http://www.urologyhealth.org/urologic-conditions/prostate-cancer/treatment/hormonal-therapy

You might be a candidate for TURP if...

  • You have Stage III or IV cancer
  • Disclaimer: TURP does not cure prostate cancer, but it does relieve urinary blockage
  • Sources: (1) http://www.prostatecancer.ca/Prostate-Cancer/Treatment/TURP
  • (2) http://www.cancer.gov/types/prostate/hp/prostate-treatment-pdq#link/_1908_toc

You might not be a candidate for TURP if...

  • You have a low life expectancy
  • You have inguinal hernia
  • You cannot assume the lithotomy position
  • You have bladder stones
  • You have a prostate adenoma > 75 mL
  • You have certain urethral conditions
  • You have an untreated UTI
  • You require bladder diverticula surgery
  • You have blood clotting problems
  • Source: http://www.urology-textbook.com/turp-prostate-resection.html

You might be a candidate for cryotherapy if...

  • You have early-stage prostate cancer
  • Your cancer is entirely within the prostate or has broken through the prostate structure, but has not yet spread
  • Your cancer recurs after radiotherapy
  • Sources: (1) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-cryosurgery
  • (2) http://prostatecanceruk.org/prostate-information/treatments/cryotherapy

You might not be a candidate for cryotherapy if..

  • You have a large prostate
  • Your cancer has spread (metastasized)
  • You have severe urinary problems
  • Sources: (1) http://cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-cryosurgery
  • (2) http://prostatecanceruk.org/prostate-information/treatments/cryotherapy

Summary

  • The chances of getting diagnosed with prostate cancer are high
  • The odds of dying of prostate cancer are not very high. Even if diagnosed, especially at an older age, you are more likely to die of other causes than prostate cancer.
  • The screening tests are not very reliable or accurate. "False-positives are common. Only about 1 in 4 men with an abnormal PSA test result turns out to have prostate cancer." (http://www.mayoclinic.org/diseases-conditions/prostate-cancer/in-depth/prostate-cancer/art-20048087)
  • Over diagnosis can lead to over treatment in patients who might very well never need it
  • Even if diagnosed, not all patients require urgent treatment, and may be eligible for watchful waiting or active surveillance
  • There are multiple treatment options
  • While some men would definitely benefit from screening, there are others who would not
  • Routine prostate cancer screening is not recommended for men younger than 40 or older than 70 and/or with a life expectancy of less than 10 years

So should I or should I not get screened for prostate cancer?

The answer to that question depends on a number of factors.


  1. Your age: "Although only 1 in 10,000 men under age 40 will be diagnosed, the rate skyrockets up to 1 in 38 for ages 40 to 59, and 1 in 15 for ages 60 to 69." (http://www.pcf.org/site/c.leJRIROrEpH/b.7425707/k.7A02/10_Myths_and_Misconceptions_About_Prostate_Cancer.htm). Men under 40 or over 70, or with life expectancy of less than 10 years, are unlikely to benefit from routine prostate cancer screening.

2. Your family history: Did you have a first-degree relative (your father or your brother) diagnosed with prostate cancer, especially at a younger age? If yes, you are twice as likely to develop prostate cancer ( http://www.pcf.org/site/c.leJRIROrEpH/b.5802027/k.D271/Prostate_Cancer_Risk_Factors.htm)

3. Your race: African-American men are more likely to develop, and succumb to, prostate cancer, than men of other races (http://www.pcf.org/site/c.leJRIROrEpH/b.5802027/k.D271/Prostate_Cancer_Risk_Factors.htm), while Asian and Latin-American men have the lowest prostate cancer incidence (http://www.healthline.com/health/prostate-cancer-risk-factors#RiskFactors3).

Treatment choices

If given a choice between active surveillance and other forms of treatment, such as surgery, which would you choose?

See results

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