WASHINGTON, DC—To screen or not to screen? That is the question that many male patients must ask themselves when it comes to prostate cancer. While screening for cancers such as colon and cervical may benefit a person’s health, the benefits associated with prostate cancer screening are less clear. “It is difficult, with even decades of research, to show that screening for prostate cancer helps with mortality or decreases the burden of disease,” said Army Col Gary Wheeler, who is chief of the department of medicine at Madigan Army Medical Center and the internal medicine consultant to the Army Surgeon General. Though prostate cancer is rare in men younger than 40, it is the second most fatal cancer in US men. It is estimated that approximately $8 billion is spent on prostate cancer treatment each year in the United States, according to the National Cancer Institute.

Last year, the US Preventive Services Task Force updated its screening guidelines to advise against the routine use of prostate-specific antigen (PSA) testing to screen for prostate cancer in men age 75 and older because the potential harms of PSA testing for men in this age group may outweigh any benefits. For men under 75, the panel concluded that there was inadequate evidence to say whether treatment for prostate cancer detected by screening improves health outcomes. Previously, the Task Force concluded that there was insufficient scientific evidence to recommend screening for all men, and found inconclusive evidence that early detection improves health outcomes. “The tools that we have at our disposal to screen for the disease have to date not shown an improvement in mortality, and in fact the burden of screening in some cases shows real potential to do harm,” said Dr Wheeler.

Prostate Cancer Screening

Since the risk of prostate cancer increases with age, active duty servicemembers are often not diagnosed with the condition until after they have retired from service. According to the NCI, the median age of diagnosis for prostate cancer is 68 and the median age of death from it is 80. “It is not at all typical that a patient comes to us on active duty with prostate cancer that requires them to leave the service. It is a little bit of a different demographic. It tends to be much older men than those who are still in uniform,” said Dr Wheeler. However, a diagnosis of prostate cancer for a servicemember on active duty would not necessarily prohibit him from continuing his service in the Army. “If you look at the retention standards, they say that people must go through a medical board if their cancer is unresponsive to therapy, or if the side effects or treatment of that cancer causes disability to where they can’t perform their duties,” Dr Wheeler noted.

In his practice, Dr Wheeler explains the potential benefits and detriments of prostate screening to patients in order to help them determine whether they want to undergo the test. A potential benefit of screening is that it can detect cancer at an early stage, resulting in prompt treatment. A potential downside of detecting the cancer through screening is that it may lead to unnecessary treatment. Some prostate cancers may never affect a man’s health if left untreated, and treatment may lead to serious side effects such as impotence and incontinence.

The challenge for physicians is in determining which prostate cancers will be aggressive and may benefit from therapy. “We know from autopsy studies of men in their 80s who die of other causes that if you examine the prostate, most will have prostate cancer and yet the man died never knowing he had it. So clearly the prostate cancer did not harm that patient. The challenge is to find the aggressive disease in the younger men that would cause harm or death and to distinguish that from the older man who may have a much less aggressive disease for whom no treatment is needed,” Dr Wheeler explained. Ultimately, some patients opt for early detection,

while others do not. Researchers continue to seek better and more reliable ways to screen prostate cancer and to identify which prostate cancers grow fast enough to require treatment. “There are very intense efforts in clinical research to find a better screening tool. If we are able to find markers that can help us predict those cancers that take life prematurely, we can get to the point where all of us would like to be—to find disease states that we can treat and reduce harm and death,” said Dr Wheeler. One study published in the May 5 issue of Annals of Internal Medicine examined specific biomarkers that might help in guiding treatment. In that study, researchers reviewed health records for 1,313 US veterans with prostate cancer who were at least 50 years old to determine whether certain molecular factors are associated independently with death from the disease. The researchers found that BCL2, p53, or high microvessel density in prostate cancer biopsies are associated with increased risk for death in these patients.

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