Prostate Cancer Awareness Campaigns Could Cause Confusion

In recognition of September as National Prostate Cancer Awareness Month, many of your male patients (and their wives) may have been reading, hearing and seeing news reports, commercials and public service announcements encouraging men to be screened for the disease.

However, the AAFP has concluded that current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75, and the Academy actually recommends against screening men 75 and older.

The AAFP recommendations agree with those of the U.S. Preventive Services Task Force, or USPSTF.

Family physician Michael LeFevre, M.D., M.S.P.H., a member of the USPSTF, said mixed messages about prostate cancer screening could be confusing for men.

"The public tends to get battered back and forth by the latest press articles about one disease or another, and they tend to rely on their personal physician to help sort it out," said LeFevre, who is a professor and assistant chair in the department of family and community medicine at the University of Missouri, Columbia. "Unfortunately, I think it's (also) difficult for physicians, who hear different recommendations from different organizations about particular diseases."

LeFevre said that the vast majority of the messages coming from professional medical and consumer health organizations and public health agencies -- including the AAFP, the USPSTF and the American Cancer Society -- about prostate cancer screening are consistent in saying that men should be given all the information they need to make informed decisions about whether to be screened for prostate cancer.

The USPSTF last updated its recommendations in 2008, with the largest change being the recommendation against screening men ages 75 and older because, the task force said, "there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits."

The task force found that for men of all age groups, treatment for prostate cancer detected by screening can cause moderate to substantial harms, including erectile dysfunction, urinary incontinence, bowel dysfunction and death.

Therefore, the task force said, physicians should not order a prostate-specific antigen, or PSA, test without first discussing with the patient the potential but uncertain benefits and the known harms of screening and treatment.

The USPSTF said more than 27,000 American men died of prostate cancer in 2006, and more than 200,000 men were diagnosed with prostate cancer in 2007. However, the task force also said that the median age of death from prostate cancer from 2000 to 2004 was 80, and 71 percent of deaths occurred in men older than 75.

Furthermore, the task force said, a substantial proportion of prostate cancer cases detected with current screening methods will not cause symptoms during a patient's lifetime.

Results from two large, long-term prostate cancer screening trials were reported March 26 in the New England Journal of Medicine.

A U.S. study of prostate, lung, ovarian and colorectal cancer screening showed overall rates of death from prostate cancer were very low in both the screened group and the control group, and no significant difference in prostate cancer mortality rates was seen between the two groups.

A European study found that the rate ratio of death from prostate cancer in the screened group compared with that seen in the control group was 0.80, and the absolute risk difference was 0.71 death per 1,000 men. That means that more than 1,400 men would have to be screened, and 48 additional cases of prostate cancer would have to be treated, to prevent one death from prostate cancer.

In addition, a study published online Aug. 31 in the Journal of the National Cancer Institute found that the introduction of PSA screening in the mid-1980s has resulted in more than 1 million additional men being diagnosed and treated for prostate cancer in the United States, with the most dramatic growth seen among younger men. "Overall incidence of prostate cancer rose rapidly after 1986, peaked in 1992, and then declined, albeit to levels considerably higher than those in 1986," said the study authors.

"Using the most optimistic assumption about the benefit of screening -- that the entire decline in prostate cancer mortality observed during this period is attributable to this additional diagnosis -- we estimated that, for each man who experienced the presumed benefit, more than 20 had to be diagnosed with prostate cancer," they noted.

"Given the considerable time that has passed since PSA screening began, most of this excess incidence must represent overdiagnosis," the authors wrote.

In an accompanying editorial, Otis Brawley, M.D., chief medical officer of the American Cancer Society, said prostate cancer screening has resulted in substantial overdiagnosis and unnecessary treatment that may have saved relatively few lives.

"It's important for men to understand there is uncertainty," LeFevre said. "There isn't definitive evidence that we can prevent death from prostate cancer by screening. There is clear evidence of harms."

LeFevre said he gives his male patients a short talk about prostate cancer screening during which he describes two men. One appears healthy, feels good and wants to be left alone. The other worries about cancer, wants to know if he has it, and wants to do something about it if, in fact, he has prostate cancer.

LeFevre then asks the patient which man he is most like.

"It's important that they have a choice," he said.