How a teenager’s question helped this prostate cancer expert reframe the great screening debate
Slogans at cancer awareness events are simple; reality is not.
"Dad, why should all men get checked for prostate cancer?" my 13-year-old son asked me recently. Not a question you get from most kids, but we were at a 5K race sponsored by a prostate cancer advocacy group, so the "go and get checked" message was prominent.
"Well … that's actually quite complicated," I told him. "Not all men should. Let's talk about it after the race."
As the runners — many of whose lives had been touched by prostate cancer — gathered on a beautiful crisp autumn morning, I looked at my budding teenager with AirPods in his ears and thought that children often hit on the most difficult questions.
A slam dunk?
In 2018, more than 160,000 American men will be diagnosed with prostate cancer. Fewer than a fifth of men with prostate cancer will die from it. Yet it still is the second-leading cause of cancer death in U.S. men (lung cancer is the deadliest), because it is so common.
Screening might seem to be a slam-dunk for prostate cancer, given that this cancer is common, curable in early stages, and usually slow-growing, leaving time to intervene.
Yet, the problem is that screening helps some men but can expose many to risks and even harms. The decision to screen is like any important decision in our lives — a matter of weighing risks against benefits. And to balance risks appropriately, one has to understand them.
Many shades of cancer
"Dad don't wait for me. Run ahead," my son urged me, somewhat breathlessly. "We run together," I answered, matching my pace to his.
But as I was pondering how to answer his screening question, my son was accelerating.
How many men and women who were running with us, I thought, could have safely avoided the massive disruption in their lives that prostate cancer can cause?
As a surgeon who treats genitourinary cancers, every week I meet men who are newly diagnosed with prostate cancer. My advice ranges from, "this cancer requires no treatment," to, rarely, "we cannot cure you, but we can control this for many years to come."
In fact, the screening controversy stems from this fact that prostate cancer comes in so many different shades. The scenario that fuels enthusiasm for screening is as follows: A healthy man has a blood test and a physical exam to check for prostate cancer. The doctor finds something and sends him for a biopsy. It's cancer. The man is treated, without any notable side effects, and his life is saved.
Yet, this isn't what usually happens, for a number of reasons:
Screening tests often reveal abnormalities in men who don't have prostate cancer (known as a "false positive result"). This means unnecessary emotional distress, prostate biopsies, and medical follow ups.
Screening tests may miss aggressive cancers (a "false negative result"), thus giving a false sense of security.
Some aggressive cancers discovered through screening have already spread, meaning that early detection is of dubious value. Thankfully, this scenario is rare.
Men can run into problems after prostate biopsy. Some can experience serious infections, inability to urinate (necessitating a temporary bladder catheter), or bleeding in the urine or stool that can be severe enough to require hospitalization. Newer biopsy techniques that avoid the rectum (transperineal biopsies) are now used at many centers, avoiding some, but not all, of these risks.
Perhaps most important, a very large proportion of men diagnosed with prostate cancer harbor disease that grows so slowly that it will not shorten their lives or even cause symptoms. One large study of men with low-risk prostate cancer who underwent a "wait and see" strategy known as active surveillance found that just one in 1,000 died of prostate cancer after 15 years of follow up. Yet the diagnosis is still enormously disruptive to the lives of men and their families. Doctors call this "overdiagnosis," often leading to "overtreatment." Imagine having treatment that could damage your sexual or urinary function for a condition that was never destined to cause you harm? This happens all too often with prostate cancer.
Minimizing the risks
Thankfully, overdiagnosis and overtreatment are coming into increasingly better focus in the prostate cancer field, with two main strategies:
Minimize testing of patients unlikely to benefit from screening.
Minimize treatment of patients with low-risk cancers.
A number of medical organizations have proposed various screening guidelines, and the differences reflect the contrasts in opinion on balancing risks and benefits. The guidelines largely agree that men 70 years and older are very unlikely to benefit from screening but may be harmed by it. Another point of agreement: the importance of shared decision-making between physicians and patients. Before any screening, patients should understand what's involved.
Minimizing treatment of low-risk prostate cancer is equally important. Active surveillance — where men are not treated but are carefully monitored for disease progression — is a critical strategy to avoid unnecessary risks. Though I am a surgeon, some of my most satisfying patient encounters are when I can tell a man that his best next step is to do less rather than more.
At the finish line
"Dad, I smoked you!" my son yelled as I crossed the finish line, some time after he had pulled ahead.
At the next race, I hope I'm in better shape and can keep ahead of my son. But even more, I hope the message at such events becomes a bit more nuanced.
"Screening is complicated. Get educated, then talk to your doctor," would be a better public health message. It is just too easy to fall behind without proper preparation.
Alexander Kutikov, MD, FACS, is a professor and chief of urologic oncology at Fox Chase Cancer Center, as well as a member of the Inquirer's Health Advisory Panel.