Peter Griffin is now over fifty years old and every time he goes to see his family physician for his routine preventive primary care his family doctor asks him about lower urinary tract symptoms such as:
- Poor stream
- Terminal dribbling
- Incomplete voiding
Lois is concerned something might be wrong because he frequently has to get up through the night to void. Peter says this is normal and of no concern. Lois says that she heard on Dr. Oz that there might still be a role for PSA testing, after all she participates in yearly breast cancer screening. (1)
But Peter finds he is somewhat confused why there is such a focus on these symptoms. He recalls reading in the local paper that the U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. (2) He begrudgingly agrees to once again go see his doctor to please Lois.
He waits patiently in the little exam room in a little paper gown feeling very vulnerable. Dr. Doyle comes in and says, “Prostate cancer is the most common non-skin cancer and the second leading cause of cancer death in men in the United States.”
Now Peter has been through this ritual before and he did his homework before this encounter. Peter says, “what is a biologically significant Prostate Cancer”? This pauses Dr. Doyle in his tracks as he lowers his gloved hand.
Peter doesn’t hesitate, he fires a second volley by saying, “doesn’t prostate specific antigen screening presuppose that most asymptomatic prostate cancer cases will ultimately become symptomatic cases that lead to poor health outcomes.”
Dr. Doyle relents for the moment and says, that prostate cancer screening is an increasingly contentious debate. He is pleased to hear that Peter is doing his reading on this important topic. Dr. Doyle says that each man has to take into consideration his particular risk factors and preferences when considering the risks and benefits of screening.
Peter pushes a little further asking how good the digital rectal exam is at detecting prostate cancer. After some digging around Dr. Doyle located a reference which states that DRE alone has a sensitivity of 27% and specificity of 33% or a positive predictive value (PPV) of only 18%. PSA alone by comparison has a sensitivity of 35% and a specificity of 75% and a PPV 28%. Combined (DRE plus PSA testing) has a better specificity, or ability to rule in the presence of prostate cancer (Sensitivity 38% – Specificity 92% – PPV 56%).
Though again this is just a screening test rather than a true diagnostic test, if the concern remains high then Peter would need a prostate biopsy, and like all surgical procedures this comes with some risk of pain, bleeding and infection, not to mention hemospermia and emotional stress.
This is all starting to make Peter’s head hurt. Dr. Doyle concedes it is something he also struggles with, that from his reading of the literature there is no good evidence to suggest improved morbidity or mortality outcomes for those who undergo screening and that for any cancer-screening program to be effective, there must be curative therapies.
Presently the only robust evidence of curative benefit exists for radical prostatectomy a procedure which has considerable risk on its own.
Dr. Doyle goes to the National Institute of Health website for information on Prostate Cancer Screening and sees that it now reflects a more balanced approach suggesting patients and providers weigh individual risk and preferences when considering prostate cancer screening (3). Dr. Doyle finds this helpful info-graphic on the NIH website which is from the USPSTF 2012 (4) report which helps better summarize the risks and benefits of screening.
After this frank discussion Peter says he would still like to proceed with the DRE and PSA testing, but states that he would do serial testing and watchful waiting if he had concerns before jumping to a prostate biopsy. Dr. Doyle says this is reasonable and asks Peter to position himself on the exam table for the exam.
Let us know what resources you use in your practice to counsel men about prostate cancer risk and the benefits and risk of screening.
For more details and complete references you can review a presentation I made on Prostate Cancer Screening back in 2011 by clicking here –> Prostate Cancer