Prostate Examination: New Study Suggests Not as Effective as Believed

Prostate examinations and cancer screening may deliver false positivesA new study led by Mathieu Boniol, MD of Hospices Civils de Lyon in Lyon, France was presented at the European Cancer Congress 2013 in Amsterdam (Abstract 1481) and the study findings suggest that ROUTINE prostate specific antigen (PSA) prostate examination and cancer screening does more harm than good, and should not be done. The PSA test is believed by many to be one of the landmark discoveries of the 20th century.

Prostate Examination: Friend or Foe

The new study was based on a model that found that routine PSA screening in 1,000 men aged 59 to 69 would avoid only one prostate cancer–specific death and one high-risk prostate cancer. Dr. Boniol and his colleagues estimated that for 1 cancer death to be prevented, an additional 154 biopsies would have to be performed, of which 9 would require hospitalization for severe adverse events and another 0.2 deaths would result from biopsy complications.

The new study was funded by the International Prevention Research Institute, Lyon, France and conducted in France, where 80% of the male population undergoes routine PSA screening, usually ordered by a general practitioner. Dr. Boniol noted that in the 1980s, before the advent of PSA testing, the incidence of prostate cancer in France was 5%, and disease-specific mortality was 2%. Now, more than 80% of men aged 65 years have received a prostate examination test during the past 3 years, the prostate cancer incidence is now 14%, almost a 3 fold increase in last 30 years but the risk of prostate cancer-specific death still remains the same at 2%.

The latest study suggests that the PSA test itself is not that reliable and should not be used to routinely screen for prostate cancer for the general population until better tests or markers are established. This is because even though many more early prostate cancer cases are diagnosed using the PSA test, the prostate cancer mortality rate has NOT improved and this suggests that the early prostate cancers found using the PSA test are not that lethal or aggressive. It is important to point out that PSA screening is still important in men with risk factors, such as family history of aggressive prostate cancer and African American race.

Dr. Boniol points out that over diagnosis of early prostate cancer has adverse consequences for the patients because it usually leads to overtreatment, which in turn exposes them to harmful side effects of primary treatment with surgery or radiation—impotence, urinary and fecal incontinence and other side effects that severely affect their quality of life.

Sadly, some urologists are slow to discuss with their patients about the pros and cons of prostate examination screening for prostate cancer but are quick to order for PSA tests even though none of their problems have anything to do with the prostate. Even the prestigious Mayo Clinic in Rochester, Minnesota, ranked third in the most recent U.S. News & World Report’s annual rankings of the USA’s best hospitals, recommends offering PSA screening annually to men ages 50 to 75 with a life expectancy greater than 10 years, to African-American men ages 45 to 75 with a life expectancy greater than 10 years, and to men ages 45 to 75 years with a positive family history of prostate cancer and a life expectancy greater than 10 years. The big problem with doing annual PSAs on everyone from ages 50 to 75 is that it will generate plenty of abnormal lab results and this will lead to plenty of biopsies and of course, plenty of early prostate cancer diagnoses.

Medical prostate examinationIt is that old cliché: “To a man with only a hammer every problem looks like a nail” and when an urologist sees early prostate cancer, his natural instinct is to recommend his patient to cut it out because it is after all a “cancer”, the most dreaded word in the English language. Some urologists are quick to recommend surgical removal of a prostate tumor because they cannot be absolutely sure that the cancer is not aggressive and it is a sad fact that many, if not all doctors in America practice a certain degree of “defensive medicine” in order to avoid malpractice lawsuits.

A great deal of medical evidence has now surfaced that shows that prostate cancer often grows so slowly that many men with prostate cancer “die with it, rather than from it.” As a matter of fact, about 90% of all prostate cancers remain dormant and clinically unimportant for decades.

Source: European Cancer Conference 2013 (ECCO-ESMO-ESTRO). Abstract 1481. Presented September 30, 2013

Prostate examination