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While 64% of men will develop hidden prostate cancer by their 60s, their lifetime risk of being diagnosed with prostate cancer is only about 11% (the average risk of dying from prostate cancer at age 80 is 2.5%). So most men get prostate cancer, but they die from the tumor, not from it. Most men with prostate cancer live their lives without even knowing they have it. That's one of the problems with screening. Many prostate cancers that are discovered may not have caused any harm even if they had not been detected. Still, not all men are so lucky. About 30,000 Americans die from prostate cancer each year. So should you get a PSA prostate screening test or not?
PSA stands for prostate-specific antigen, an enzyme secreted by prostate cells that liquefies semen and cervical mucus to promote fertilization. Elevated levels in the blood can be a sign of prostate cancer, which led to its FDA approval as a screening test for early detection of prostate cancer in the 1990s. If it returns to a high value again, the test is usually repeated. If it is still high, the next step is usually a transrectal ultrasound-guided prostate biopsy. If you have cancer, options include surgery, radiation, chemotherapy, or delaying treatment.
However, the United States Preventive Services Task Force (USPSTF), a major independent scientific panel that sets evidence-based clinical prevention guidelines, has not recommended routine PSA testing, as have the American College of Preventive Medicine, the American College of Family Physicians, and the American College of Family Physicians. The majority (85%) of medical professionals in developed countries around the world opposed it.
However, in 2018, the USPSTF shifted to “prostate cancer screening decisions are up to the individual” in summary judgment, which is more consistent with the American Urological Association’s “shared decision-making” position. American College of Physicians and American Cancer Society. That means men need to know the risks and benefits and make their own decisions. However, according to the latest USPSTF recommendations, men who are on the fence and who do not express a clear preference for testing should not be tested.
An international panel of experts recently concluded that clinicians need not feel obliged to address this systematically. We determined that most men would decide to refuse PSA testing considering the clear harms and small, uncertain benefits. But it's up to you. I personally declined, but let's look at the numbers.
Similar to the 92% of women who either did not know or overestimated the mortality reduction from mammography by a factor of 10, 89% of men either greatly overestimated the benefits of prostate cancer screening or had no idea about it at all. Most people thought that 50 prostate cancer deaths out of every 1,000 men who were screened regularly could be prevented, but in reality it was closer to 1. But isn't it worth getting a few blood tests, even if you only have a 1 in 1,000 chance of not dying from cancer? But the downside is more than just inconvenience.
About 1 in 7 men who have a PSA test will have a positive result, but two-thirds of them will have normal biopsy results. So, out of every 1,000 men who are regularly screened, about 150 will receive a false alarm and undergo an unnecessary biopsy, which can lead to minor complications such as painful and bleeding ejaculation and, in about 1% of cases, more serious complications such as blood-borne infections. It can cause serious complications. Hospitalization is required. However, the biggest damage is overdiagnosis. Unnecessary biopsies are bad enough, but they're nothing compared to unnecessary cancer treatment.
Large randomized trials have shown that 20 to 50 percent of men diagnosed with prostate cancer will never develop symptoms during their lifetime. They would have been none the wiser if they had not been tested. But now you may be heading to the operating table unnecessarily. About 3 in 1,000 men die during or shortly after radical prostatectomy. This may help explain why prostate cancer screening does not help overall mortality. For every life saved, another life may die from cancer of which they had no knowledge.
Another 50 out of every 1,000 men will experience serious surgical complications. Even if the surgery goes smoothly, about one in five men will develop long-term urinary incontinence requiring the use of pads, and most men (two out of three) will experience long-term erectile dysfunction. Most men who receive radiation therapy experience long-term sexual dysfunction, and up to one in six experience long-term bowel problems, such as fecal incontinence. If this saves your life, it will be worth it. But after 16 years, screening can make you 25 times more likely to be overdiagnosed with a cancer that doesn't really matter than to avoid dying from prostate cancer. But after receiving treatment, you came back thinking the PSA test saved your life. It's like a mammogram. Those most affected by unnecessary cancer treatment feel like they have been helped the most.
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