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Are patients being informed about prostate cancer screening risks?


Get screened. It could save your life. Don’t get screened. There’s no evidence that screening saves lives.

Get tested in your 40s. Wait until you’re 55.

Get the test every year. Every four years is enough.

When it comes to screening for prostate cancer, the messages from doctors, major medical organizations and media campaigns are all over the map.

While not a new rift among the medical community, the prostate cancer screening debate has recently reignited. Healthy Debate looks at the evidence and ethics behind the mixed messages.

The evidence for and against PSA screening

The biggest and most trusted trial on prostate cancer screening began in 1993 and has since followed around 163,000 men in eight European countries. Around half of these men were randomly assigned to get screened every two to four years, depending on the country, while the other half weren’t screened. Most of the men were above 55 at the time of enrollment.

After 13 years of following these men, the researchers concluded that there was a benefit to routine screening. It prevented one prostate cancer death for every 781 men who were screened. The study did not find that those screened lived longer, overall, than those in the non-screening group.

On the flip side, the researchers also documented harms of screening. For every one life saved from prostate cancer death, 200-plus were found to have an elevated PSA, and a biopsy was ordered to check if prostate cancer was the reason. Out of this group, 27 men were diagnosed with prostate cancer that wouldn’t have caused illness or death, according to the European researchers. Most prostate cancers are very slow growing and never move outside of the prostate. The number of “over-diagnoses” was arrived at by comparing rates of diagnosed prostate cancer in the screening group versus the non-screened group.

The unnecessary blood tests, biopsies and potentially unnecessary treatments can be harmful – leading to anxiety or damaging physical effects. Let’s start with the PSA test itself. While not dangerous (aside from some minor bruising), it can cause anxiety as some men might worry about the results of a PSA test. Then there’s the biopsy for those found to have a high PSA. According to Girish Kulkarni, a urologist with Toronto’s University Health Network, it’s estimated 2% to 4% of men will end up in the hospital due to an infection from the biopsy needle being inserted repeatedly into the prostate through the rectum. In very rare cases, an infection from a biopsy can lead to death.

If a prostate cancer is found, there’s the risk of unnecessary treatment. Doctors have gotten better at identifying high risk cancers that must be treated and the more common ones that can be watched. But men still get treated unnecessarily, because doctors can’t always be sure whether a prostate cancer will be aggressive, and therefore err on the side of treating. This means either surgery or radiation, both of which can cause incontinence and impotence as well as other complications. Sometimes, it’s the patients that demand treatment. The anxiety of knowing about a cancer causes 10% of low-risk patients to choose to treat it even though their doctors recommend simply monitoring it, according to recent studies.

It’s important to keep in mind that the benefits of PSA screening may be larger for men with a family history of or genetic risk factors for aggressive prostate cancer, but not enough research has been done on this particular population to prove or dispute this theory.

In summary, for a small number of people, PSA testing will mean they avoid death from prostate cancer. For many others, PSA testing will lead to more tests, more anxiety, and complications from tests and treatments. “Some people will focus on the benefits side and other people focus on the harms side,” explains Neil Bell, a family physician and chair of the prostate cancer screening working group of the Canadian Task Force on Preventive Health Care. “You have to consider patient preferences and values.”

The Task Force has a ‘weak recommendation’ against PSA screening for men 55 to 69, which means the reviewers concluded the harms outweigh the benefits, but only slightly. Other organizations, like the Canadian Urology Association, recommend that prostate cancer screening “be offered to all men 50 years of age with at least a 10-year life expectancy.” Some organizations, like Prostate Cancer Canada, even recommend PSA testing to men in their 40s and 70s, though most experts say the existing evidence doesn’t support PSA screening for these age groups.

Are men being adequately informed on the risks and benefits of PSA screening?

Despite divergent opinions on the utility of testing, there is generally consensus on this point: before patients go for PSA testing, they should be informed of the risks and the benefits.

In reality, this doesn’t always happen.

The conversations we had with doctors and patients reveal that some doctors automatically send men in their 50s for PSA blood tests, without counselling them on risks. Others don’t bother with PSA testing unless the patient brings it up (in which case they discuss the pros and cons before referring a patient for the test). And others talk to every male (usually those 50 or above) about the risks and benefits and let the patient decide. “Many physicians are choosing not to have the discussion,” agrees Bell, but because no study has examined Canadian physician practices around PSA testing, we don’t know how often the risks and benefits conversations are skipped.

If patients aren’t getting information from their family doctors, they may be hearing messaging from other health organizations – at least on the benefits side. In Alberta, the “Man Van,” a service funded by the Prostate Cancer Centre at Rockyview General Hospital in Calgary, offers free PSA tests on site at workplaces, events and public places. With a logo stating ‘Get Checked’ The Man Van goes out a few times a week and draws blood to send for PSA levels of 55 men within three hours. Linda McNaughton, director of community and strategic initiatives, says Man Van employees counsel men to explain a high PSA does not mean prostate cancer. However, the men aren’t informed of the very small benefit (that 781 men need to be screened to prevent one prostate cancer death, according to the European trial) nor are they informed of the harms of testing – the risks involved with further testing and treatment. “We don’t go that far…we’re just doing awareness,” explains McNaughton.

Likewise, Prostate Cancer Canada spreads messages like “early detection saves lives, especially when it comes to prostate cancer,” but fails to mention any of the risks of screening in its press releases or video. (The organization’s website does briefly mention some “limitations” of the PSA test on its website, including “unnecessary tests and treatment,” but the harms of those tests and treatments aren’t described.)

The two organizations also tend to focus on individual stories of men, rather than the evidence on the harms and benefits – leaving patients with potentially distorted views. For instance, Prostate Cancer Canada’s website features a video where a man in his 40s is tested and is reassured to know his PSA is in the normal range. McNaughton also justifies her organization’s screening push by talking about their patients’ stories, rather than studies. “We see guys who have advanced prostate cancer because their family doctor heard that you shouldn’t be testing them,” she says. “All they can do is take hormonal treatment until they die. It’s in their bones…it’s a nasty cancer.”

Paul Glazsiou, a general practitioner and professor of evidence-based medicine in Queensland, Australia, thinks such stories are used with good intentions. People who treat or represent patients with prostate cancer want to believe that screening could prevent the kind of suffering they see, he explains, even though the trials show “most of the deaths from prostate cancer still occur, even with screening.”

Meanwhile, people like McIntyre and Edmonds routinely encounter patients who claim their lives were saved because of PSA testing – because it’s a common belief among patients that all cancers are deadly. But men often don’t share details of negative side effects. “Someone might say ‘I had prostate cancer five years ago and it was treated and now I’m running marathons,’” explains Ian Tannock, who recently retired as a medical oncologist and researcher at Princess Margaret Hospital. “You don’t hear about the men who can’t have sex and are leaking in their pants,” he says. Tannock argues doctors have an obligation to inform patients on the basis of high-quality evidence, not potentially unrepresentative stories of the individual patients they see.

Shared decision making works in theory, but what about practice?

PSA screening conversations are incredibly complex, which partly explains why some doctors aren’t having these conversations and why prostate treatment groups choose to focus on patient stories over data.

“Having the conversation around harms and benefits requires discussing complicated statistics, which nobody likes to do,” says Ben Addleman, a family physician in Calgary. Addleman does have these conversations with his patients, but they’re time consuming, often stretching beyond 10 minutes.

Dr. Bruce Topp, a family doctor in Toronto, says he tends to send men in their 50s and 60s for PSA testing because he thinks it’s beneficial, especially in light of improved diagnostic practices that reduce the risk of unnecessarily being treated. He will occasionally have conversations with patients on the harms and benefits, if a patient has questions, for example. Generally, however, he finds patients find the information too difficult to digest and don’t want the choice. “Most of the time, they say, ‘You do what you think is best.’”

Glasziou does the opposite; he doesn’t routinely screen patients, and doesn’t mention screening unless his patients ask about it. “I have a few minutes to discuss any preventative procedures, and the number one priority is going to be smoking,” he says. Because deaths from prostate cancer are relatively rare, “prostate screening is a long way down that list.”

Glasziou wonders if counselling on PSA is even possible during a doctor’s appointment. He was involved with a study in which 11 men were educated on the pros and cons of PSA screening and then asked about their opinion on screening policies. “It took them the full two days to really grapple with all of the issues,” he says. (They ultimately concluded the government shouldn’t fund PSA screening campaigns but should pay for counselling regarding the test.)

To reduce the time burden, some doctors are choosing to direct patients to websites, videos and pamphlets about PSA screening pros and cons that they can read on their own time.

Michael Barry, a Boston-based family doctor and chief science officer of Healthwise, argues doctors have an ethical obligation to offer PSA testing and counsel patients, whether through a conversation or take-home resources. That’s because some men will want the test and some men won’t – based on the same information. His research saw over 1,000 men educated via a decision aid on PSA screening. Out of those who understood the information correctly “about two thirds of them don’t want a PSA and a third of them do.”

Where do you stand on prostate cancer screening?

  • I would not get a PSA screening test and/or recommend PSA screening to a loved one. (66%, 45 Votes)
  • I would get routine PSA screening tests and/or recommend PSA screening to a loved one. (34%, 23 Votes)

Total Voters: 68

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13 comments

  1. Murray Krahn

    PSA screening is a classic example of a preference sensitive decision. There is a large literature on mens’ and families’ preferences for outcomes, as well as preferences for screening.

  2. Patrick Fafard, GSPIA, University of Ottawa

    This is a great overview of the science and the ongoing debates. What is missing is the policy dimension.

    Whether someone agrees to get a PSA test may be influenced by whether or not the provincial government is willing to pay for it. In Ontario, for example, the Ministry of Health does not endorse prostate cancer screening using the PSA test. As a result, OHIP does not pay for the test in men with no symptoms. The same holds true in B.C. I expect that for men in these provinces the lack of funding is a signal, to at least some, that the test is controversial and influences their decision to proceed with the test, as much or more as what their physician does or does not say.

    However, in other provinces, such as Saskatchewan, Quebec and Alberta, it would appear that the test is a funded service, even for asymptomatic men when ordered by a physician.

    Why some provinces endorse screening for prostate cancer and are willing to cover the costs of PSA testing even in asymptomatic men while other provincial governments do not is an important question. It speaks to how the science – and in this case scientific debate – gets translated into policy. In effect, I expect that what determines whether a man gets the PSA test is very much influenced by the decision by a provincial government to fund the test for screening purposes. The science matters, but even more important is how the provincial government has chosen to interpret the science.

  3. Stuart Edmonds

    We applaud Healthy Debate’s effort to clarify a very confusing issue. Encouraging discussion regarding an equivocal topic such as this is a helpful way to stimulate the consensus-building process and mitigate confusion. However we are disappointed that the discussion presented has not encompassed all the key literature on the subject.

    We feel the need to clarify Prostate Cancer Canada’s position with respect to screening for prostate cancer with PSA. In agreement with prostate cancer experts, Prostate Cancer Canada advocates for “smart screening” which takes a man’s personal risk into account. This involves getting a PSA test at age 40 to establish a baseline number which then becomes part of the man’s risk profile to determine when the next PSA test needs to occur. Rather than testing every man annually, smart screening involves a tailored approach to prostate cancer screening with individualized follow up and care. This approach is in line with the Melbourne Consensus Statement (http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/) and the European Association of Urology (http://www.europeanurology.com/article/S0302-2838(13)00666-0/abstract/early-detection-of-prostate-cancer-european-association-of-urology-recommendation) – both highly credible expert groups that were omitted from the above article.

    In the case that prostate cancer is discovered to be aggressive, the likelihood that it will be caught early enough to treat will be significantly increased with the PSA test – the declining mortality in Canada (approximately 40% over the last 20 years) has been attributed to not only improved treatments but also earlier and better detection (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698782/). In the case that prostate cancer is discovered to be small and slow-growing, on the other hand, the Canadian-developed method of active surveillance can be employed to avoid hastily over-treating less aggressive tumours. Also contrary to the article, in Canada in one of the largest, longest running active surveillance cohorts under 2% are treated due to patient preference (http://www.ncbi.nlm.nih.gov/pubmed/25512465).

    In the US, where the US Preventive Services Task Force recommended against PSA testing in 2011, there is now emerging data (http://meetinglibrary.asco.org/content/140836-159) that demonstrates consecutive years of increased incidence of intermediate or higher risk prostate cancer. Our fear is that we will start to see this effect in Canada which will lead to more prostate cancer deaths.

    Finally, contrary to what is stated in the article, Prostate Cancer Canada strongly encourages informed and shared decision making and provides information about the pros and cons of PSA testing on its website (http://www.prostatecancer.ca/Prostate-Cancer/Testing-and-Diagnosis/The-PSA-Test#.VbFFa_lVhBe).

    Stuart Edmonds PhD
    Prostate Cancer Canada

    • Wendy Glauser

      Dear Dr. Edmonds,

      Thank you for your comment and I do hope those interested in learning more about the nuances of the PSA debate follow the links above.

      The earlier version mentioned that Prostate Cancer Canada doesn’t mention the risks of screening. We regret the error and have updated the piece to explain that Prostate Cancer Canada does mention the limitations of the test to a degree.

      Finally, we decided to focus on the highest quality evidence, which the sources we spoke to indicated was the European trial. There was another large RCT from the U.S. that did not show that PSA screening reduced prostate cancer death (as Dr. Wright mentions below) but we decided not to focus on this trial due to the contamination issues you and others pointed out. As yet, we have not seen a large, randomized and controlled trial that showed a “tailored” approach to prostate screening based on baseline PSA to be more effective than non-tailored routine screening. It is for this reason we did not elaborate on this approach.

      Thank you for your further contribution to this article.

  4. Dr Charles J Wright

    I am surprised that this issue is surfacing from the depths to which it was appropriately consigned years ago. Even if the results of the trial quoted above represent the truth (which is very doubtful in view of the other trials showing no mortality benefit whatever), the imbalance of the serious toll of harms caused by PSA screening vs. the tiny potential benefit would definitively rule out the test as an acceptable screening procedure by any unbiased analysis. Aye, there’s the rub. Radical prostatectomy has become a much too popular procedure among urologists (a problem that has been exacerbated by the advent of robotic surgery), and to date leadership from the profession’s senior ranks in dealing with the disaster of PSA screening has been sadly lacking. Like some other screening procedures, PSA testing was introduced with the laudable intention of offering some hope in the battle against a nasty disease. Unfortunately the evidence over three decades has now shown that PSA fails to meet even the most basic requirements for a screening test. When did we abandon the good idea that we should not do things that cause net harm to our people?

    • Jimmy

      From the layman’s standpoint and devil’s advocate, where do you propose we go from here? It’s hard to synthesize all this blah blah blah with the final statement from my doctor being “but is YOUR decision to make”

      • Gerry Goldlist

        Very good question. What is a patient to do when his physician gives all this information including the fact that his physician doesn’t know the answer?

    • Sue Mather

      Dr Charles Wright
      I had booked a complete physical for my then 57 yearold husband in 2009 .Up until this time he had not even had a physical exam for years. I specifically requested testing ! He was a only child his mother when she died had breast cancer we didn’t at that time have alot of medical history in regarda to his maternal grandfather. He was told he was to young to worry about prostate cancer, its a old mans disease, there are to many false reads, she doesn’t reccomend it at all. The following year there were a couple of symptoms that she put off as being something all men have .Yes she orxered diabetes testing when Dave told her wad feeling like he was urinating far to much but never bothered to investigate when that came back clear. In late 2012 when the urinating became unbearable she finally ran a PSA test after Dave insisted! It was 80. By May of 2013 his diagnosis was stage 4 hormone resitant he has been now given a certain death sentence. Today he is fighting to live at 64 he has been told there may be just months .oh yes his PSA last week was 4,334 not that it really even matters now. When it mattered the most was back in 2009 when we could have seen what was happening inside .We could have had options then and it probably would have involved a prostectomy at some point but our outcome cold have seen Dave live to a ripe old age . If this was your prostate cancer story you would fully understand how silly it sounds now to us to ever be worried about a PSA TEST .Death is alot worse of a worry! Its not the PSA test that is wrong, its what is done after that matters the most.

  5. Gerry Goldlist

    We must be careful not to do a test when we don’t know what we should do with the result of the test.

    As a middle-aged man, I watched the risk-reward discussion for years. Then my PSA started to rise. I already knew that I had Benign Prostatic Hypertrophy so it was suspected that was the cause. Nevertheless, the PSA kept rising and I had to follow through with 2 biopsies, an MRI, numerous visits to the lab for blood tests and many visits to the urologist. All of these necessitated my rearranging my work life and my personal life. The unnecessary loss of time is one of my biggest complaints about my situation.

    Anxiety STILL is the major issue that I am upset about. Anxiety was due to visits to get my PSA test, risk and discomfort of the biopsies, reading the risks of the biopsy, huge anxiety prior to getting the biopsy result and the subsequent calls to my loved ones who were worried about me was the major issue that I am upset about. I started to put my life in order prior to the first biopsy. How was I to control my wife’s panic? She was in much worse shape than I am. This has been going on for a few years now and she still is panicky. All I can do is reassure her that in the worst case she will be looked after and that we had enjoyed many good and bad times together over our lifetimes.

    My doctor recommended the PSA test years ago when it was relatively new so he did know its downside. I wish I had never had that first PSA as it dragged me into the regimen that had to follow once the first test was done.

    My story is not evidence. It is an anecdote that shows how one person suffered the problems discussed in this article.

  6. DR NO BIOPSY

    You don’t get paid to not biopsy.

    Signed,

    A doctor who does not do biopsies.

    • Gerry Goldlist

      Dear Dr. No Biopsy: What was the point of your comment ? Are you implying that my doctor did a biopsy to make money and not because my PSA was rising rapidly?

  7. Bill pohlman

    The VHA (VA) recommends against screening for prostate cancer and in most instances the vet is not offered a psa or dre test; this is true for even those exposed to Agent Orange who are known to be at high risk!!!
    Our president, his challenger, and most of our nation’s leaders have had the test that is not offered to our vets..It is past time that our president issue an EXECUTIVE ORDER to rectify the situation…..

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