I just turned 60.  Several months ago I had a routine physical exam, lab work, and a colonoscopy.  I chose not to have prostate cancer screening.  This article suggests that I made a good decision – Prostate Cancer Screening Found to Save Few, if Any, Lives

Both reports were published online on Wednesday by The New England Journal of Medicine. One involved 182,000 men in seven European countries; the other, by the National Cancer Institute, involved nearly 77,000 men at 10 medical centers in the United States. In both, participants were randomly assigned to be screened — or not — with the PSA test, whose initials stand for prostate specific antigen. In each study, the two groups were followed for more than a decade while researchers counted deaths from prostate cancer, asking if screening made a difference.

The European data involved a consortium of studies with different designs. Taken together, the studies found that screening was associated with a 20 percent relative reduction in the prostate cancer death rate. But the number of lives saved was small — 7 fewer prostate cancer deaths for every 10,000 men screened and followed for nine years.

The American study, which had a single design, found no reduction in deaths from prostate cancer after most of the men had been followed for 10 years. Every man has been followed for at least seven years, said Dr. Barnett Kramer, a study co-author at the National Institutes of Health. By seven years, the death rate was 13 percent lower for the unscreened group.

The European study saw no benefit of screening in the first seven years of follow-up.

The reason screening saved so few lives, cancer experts say, is that prostate cancers often grow very slowly, if at all, and most never endanger a man if left alone. But when doctors find an early-stage prostate tumor, they cannot tell with confidence if it will be dangerous so they usually treat all early cancers as if they were life-threatening. As a result, the majority of men, whose early-stage cancers would not harm them, suffer serious effects of cancer therapy but get no benefit. Others, with very aggressive tumors, may not be helped by screening because their cancer has spread by the time it is detected.

Prostate cancer is not the only one that is hard to stop with screening. If the European study is correct, mammography has about the same benefit as the PSA test, said Dr. Michael B. Barry, a prostate cancer researcher at Massachusetts General Hospital who wrote an editorial accompanying the papers. But prostate cancers often are less dangerous than breast cancers, so screening and subsequent therapy can result in more harm.

In the European study, 48 men were told they had prostate cancer, and needlessly treated for it, for every man whose death was prevented. With mammography, about 10 women receive a diagnosis and needless treatment for breast cancer to prevent one death.

I hope that everyone will heed these studies.  My friend, and former SGIM President, Michael Barry has an outstanding editorial in this subject in the NEJM early release.  Included in his editorial is this paragraph:

After digesting these reports, where do we stand regarding the PSA controversy? Serial PSA screening has at best a modest effect on prostate-cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective but whether it does more good than harm. For this reason, comparisons of the ERSPC estimates of the effectiveness of PSA screening with, for example, the similarly modest effectiveness of breast-cancer screening cannot be made without simultaneously appreciating the much higher risks of overdiagnosis and overtreatment associated with PSA screening.

I chose not to have prostate cancer screening because I strongly suspected these data.  Sometimes the treatment is much worse than the disease.

Related posts:

1. Not all screening helps patients
2. The end of Pap smears
3. Prostate cancer mortality
4. When guidelines differ – prostate cancer
5. Prostate cancer – to screen or not

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