Some men, including those with a family history of prostate cancer,
may have a greater chance of benefit from screening and should
discuss the pros and cons with their physician to make an informed
decision, medical experts recommend in guidelines published in the
"Most, but not all, well-informed men that fully understand the
trade-offs would choose not to undergo screening," said co-author of
the guidelines Dr. Philipp Dahm of the University of Minnesota and
the Minneapolis Veterans Administration Medical Center.
"Only those men who place more value in even a small reduction of
prostate cancer mortality - these may be men at higher risk because
of a family history or because of African descent, or those simply
very concerned about ruling out a cancer diagnosis - may opt for
screening," Dahm said by email. "Shared decision-making is needed to
help them arrive at a decision consistent with their own values and
Most men with prostate cancer are diagnosed with low-risk tumors
that haven't spread to other parts of the body. Often, doctors and
patients struggle to choose between active surveillance and
treatments like surgery or radiation, because it's hard to tell
which tumors will grow fast enough to be life-threatening and which
ones might never get big enough to cause problems.
The prostate specific antigen (PSA) blood test is the only widely
available test to screen for prostate cancer. It is used in many
countries, but it remains controversial because it has increased the
number of healthy men diagnosed with and treated unnecessarily for
harmless tumors, the guidelines note.
In drafting the guidelines, experts reviewed research results from
studies involving a total of more than 700,000 men. The studies
showed that if screening reduces prostate cancer deaths at all, the
effect is very small.
"PSA screening increases the number of men who need further
diagnostic tests, such as prostate biopsy (approximately 100 per
1000 men screened), and it increases number of men diagnosed with
prostate cancer (18 per 1000 men screened)," said lead author of the
guidelines Dr. Kari Tikkinen of Helsinki University Hospital and
University of Helsinki in Finland.
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"However, many of these men would not have ever experienced any
symptoms of the prostate cancer if not diagnosed," Tikkinen said by
Because of this, it's reasonable for doctors to only bring up the
possibility of screening with men who have an increased risk, the
guidelines conclude. For most men, who don't have an increased risk,
it's fine for doctors to skip this conversation altogether.
"Prostate cancer is extremely common in men in their 70s and older
and most of these men will die `with their cancer' rather than
developing complications and dying of it, and small prostate cancers
do not cause any symptoms," said Dr. David Neal, co-author of an
accompanying editorial and a professor at the University of Oxford
in the U.K.
"Therefore, if you have a screening program which diagnoses many of
these men with rather slow growing cancers then you make a `well
person' into a patient," Neal said by email. "Then some of these men
will also be offered radical treatments with radiotherapy and
surgery and develop the complications of treatment, but because
their tumors were low risk they get no benefit from radical
treatments because they never needed it."
Because most physicians already think this way about screening, the
new guidelines are unlikely to change clinical practice, Neal added.
SOURCE: http://bit.ly/2QUA8p7 BMJ, online September 5, 2018
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