Harms Of Early Detection And Treatment
The harms of screening for prostate cancer include harms from the PSA screening test and subsequent harms from diagnosis and treatment. Potential harms of screening include frequent false-positive results and psychological harms. One major trial in men screened every 2 to 4 years concluded that, over 10 years, more than 15% of men experienced at least 1 false-positive test result.5 Harms of diagnostic procedures include complications of prostate biopsy, such as pain, hematospermia , and infection. Approximately 1% of prostate biopsies result in complications requiring hospitalization. The false-positive and complication rates from biopsy are higher in older men.3 Adequate evidence suggests that the harms of screening and diagnostic procedures are at least small.
PSA-based screening for prostate cancer leads to the diagnosis of prostate cancer in some men whose cancer would never have become symptomatic during their lifetime. Treatment of these men results in harms and provides them with no benefit. This is known as overdiagnosis, and follow-up of large randomized trials suggests that 20% to 50% of men diagnosed with prostate cancer through screening may be overdiagnosed.3 Overdiagnosis rates would be expected to increase with age and to be highest in men 70 years and older because older men have high risk of death from competing causes.
When Should Men Get A Prostate Exam
According to the American Cancer Society, men and people who were assigned male at birth should have their first prostate exam by age 50. If you have a family history of prostate cancer, you should consider having your first prostate exam at age 45.
Additionally, Black men are at a higher risk for being diagnosed with prostate cancer. For this reason, healthcare providers often recommend that Black men have their first prostate exam around age 45.
The Risks Of Prostate Screening Include The Following:
Finding prostate cancer may not improve health or help a man live longer.
Screening may not improve your health or help you live longer if you have cancer that has already spread to the area outside of the prostate or to other places in your body.
Some cancers never cause symptoms or become life-threatening, but if found by a screening test, the cancer may be treated. Finding these cancers is called overdiagnosis. It is not known if treatment of these cancers would help you live longer than if no treatment were given.
Treatments for prostate cancer, such as radical prostatectomy and radiation therapy, may have long-term side effects in many men. The most common side effects are erectile dysfunction and urinary incontinence.
Some studies of patients with newly diagnosed prostate cancer showed these patients had a higher risk of death from cardiovascular disease or suicide. The risk was greatest in the first weeks or months after diagnosis.
Follow-up tests, such as a biopsy, may be done to diagnose cancer.
If a PSA test is higher than normal, a biopsyof the prostate may be done. Complications from a biopsy of the prostate may include fever, pain, blood in the urine or , and urinary tractinfection. Even if a biopsy shows that a patient does not have prostate cancer, he may worry more about developing prostate cancer in the future.
False-negative test results can occur.
False-positive test results can occur.
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For Treatment Options Tables And Procedures & Tests Options Tables:
The numbers and percentages in our tables are based on published reports from NIH PubMed, Cochrane, FDA, NIH and other sources and can be affected by many factors such as study sizes, quality of studies, and patient populations. They are intended to give viewers an evidence-based understanding of the relative effectiveness and risks of surgeries, procedures, tests and drugs and are subject to change. Patients with their unique histories must confer and solely make medical decisions with their doctors. EvidenceMD® never renders medical advice.
What Is The Dre Procedure
A DRE is a straightforward and painless clinical exam. There may be some natural discomfort, but it is temporary.
No preparation is required, there is no need for anaesthetic and there is no risk to the patient. However, it is advisable to evacuate the intestines before the exam so that they are empty.
So, what should I expect on the day of the exam?
The patient lies on their back with their legs bent.
The stages of the exam are as follows:
The doctor begins by lubricating his finger well after putting on a glove.
The top, bottom and sides of the prostate, as well as the surface, are massaged by the end of the finger.
In this way, the size of the prostate, presence of nodules and hard areas and/or other abnormalities can be assessed easily and immediately.
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What Do The Results Mean
PSA levels may be above the baseline for various reasons other than prostate cancer.
Other that can raise PSA levels include:
- an enlarged prostate because of benign prostatic hyperplasia , for example
- prostatitis, which is inflammation and swelling of the prostate
Also, people with obesity may have lower PSA readings.
In addition, some medications may reduce PSA levels, including:
- 5-alpha-reductase inhibitors, which can help treat BPH
- aspirin, which some people take regularly as a blood thinner
- statins, which help manage cholesterol levels
- thiazide diuretics, a kind of water pill that can help reduce high blood pressure
Some herbal medicines and supplements can also lower PSA levels. A person should tell their doctor about any medications and supplements they take before undergoing the test.
High PSA levels alone do not indicate cancer. However, if a DRE also reveals changes, a doctor may recommend a biopsy for a more accurate result.
Some newer tests the results of the PSA test. They can help assess the risk for people with borderline scores to decide if they need further intervention.
The Prostate Health Index combines the results of:
Time To Say Goodbye To The Dre For Prostate Cancer Screening
Screening and assessing for prostate cancer is a major component of a urologists practice. For most urologists, part of this process includes the digital rectal examination . The DRE entails using a finger to enter the rectum and feel a patients prostate. The DRE enables physicians to make rough estimates of prostate size and identify abnormalities suggestive of PCa. It is the first physical examination urologists learn because for a long time DREs were the best and only means to screen for and detect PCa. The DRE is ingrained in urology culture, and often is joked about in film and television to the extent that some have called it the urologists handshake.
In the 1990s came the discovery of the prostate specific antigen blood test, which could help physicians identify PCa earlier in its course. Imperfect and somewhat controversial, PSA testing has become the gold standard for PCa screening. But since the adoption of PSA into urologic practice, other major advances in PCa detection have become available, such as the 4K score test or multiparametric magnetic resonance imaging of the prostate. These newer tools help urologists decide which patients should move on to a prostate biopsy and which ones can avoid it.
Limited Value in Decision-Making
Quick, Cheap, But With Drawbacks
Not Completely Obsolete
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Treatment Of Prostate Cancer
Because the efficacy of screening depends on the effectiveness of management of screen-detected lesions, studies of treatment efficacy in early-stage disease are relevant to the issue of screening. Treatment options for early-stage disease include radical prostatectomy, definitive radiation therapy, and active surveillance . Multiple series from various years and institutions have reported the outcomes of patients with localized prostate cancer who received no treatment but were followed with surveillance alone. Outcomes have also been reported for active treatments, but valid comparisons of efficacy between surgery, radiation, and watchful waiting are seldom possible because of differences in reporting and selection factors in the various reported series.
The Prostate Intervention Versus Observation Trial was the first trial conducted in the PSA screening era that directly compared radical prostatectomy with watchful waiting. From November 1994 through January 2002, 731 men aged 75 years or younger with localized prostate cancer were randomly assigned to one of the two management strategies. About 50% of the men had nonpalpable, screen-detected disease. After a median follow-up of 10 years , there was no statistically significant difference in overall or prostate-specific mortality.
Men: Cancer Screening Exams By Age
These exams are for men at average risk of cancer.
Take this checklist to your next doctors appointment. Your doctor can help you develop a more tailored screening plan if needed.
These exams are for men at average risk of cancer. If you believe you may be more likely to develop cancer because of your personal or family medical history, visit our screening guidelines page to learn about exams for men at increased risk.
- Beginning at age 40, you should speak with your doctor about the benefits and limitations of prostate screening.
- If you choose prostate cancer screening, you should get a digital rectal exam and PSA test every year starting at age 45 to check for prostate cancer if you are African American or have a family history of prostate cancer.
- If you choose prostate cancer screening, you should get a digital rectal exam and PSA test every year to check for prostate cancer
- Colonoscopy every 10 years or virtual colonoscopy every 5 years to check for colorectal cancer
Age 76 and older
If youre age 76 to 85, your doctor can help you decide if you should continue screening. MD Anderson does not recommend cancer screening for men age 85 and older.
Regardless of your age, practice awareness. This means you should be familiar with your body so youll notice changes and report them to your doctor without delay.
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When Should I Call My Healthcare Provider
If youre 50 and you havent had your first prostate exam yet, call your healthcare provider to set up an appointment. If youre at higher risk, such as if you’re Black or prostate cancer runs in your family, you should have your first prostate exam by age 45.
Furthermore, if you develop symptoms of urinary tract obstruction, schedule a visit with your provider right away. This may indicate an enlarged prostate, benign prostatic hyperplasia or a urinary tract infection.
A note from Cleveland Clinic
Most people are understandably apprehensive about their first prostate exam. Learning all you can about the process can help abate any fears or uncertainties you have. Talk to your healthcare provider about your screening options. A prostate exam is the first step in the early detection of prostate cancer and early detection is key to successful treatment.
Last reviewed by a Cleveland Clinic medical professional on 04/04/2022.
Biology And Natural History Of Prostate Cancer
The biology and natural history of prostate cancer is not completely understood. Rigorous evaluation of any prostate cancer screening modality is desirable because the natural history of the disease is variable, and appropriate treatment is not clearly defined. Although the prevalence of prostate cancer and preneoplastic lesions found atautopsy steadily increases for each decade of age, most of these lesions remainclinically undetected. An autopsy study of White and Asian men also found an increase in occult prostate cancer with age, reaching nearly 60% in men older than 80 years. More than 50% of cancers in Asian men and 25% of cancers in White men had a Gleason score of 7 or greater, suggesting that Gleason score may be an imprecise indicator of clinically insignificant prostate cancer.
There is an association between primary tumor volume andlocal extent of disease, progression, and survival. A review of a largenumber of prostate cancers in radical prostatectomy, cystectomy, and autopsyspecimens showed that capsular penetration, seminal vesicle invasion, and lymphnode metastases were usually found only with tumors larger than 1.4 mL. Furthermore, the semiquantitative histopathological grading scheme proposed byGleason is reasonably reproducible among pathologists and correlates with theincidence of nodal metastases and with patient survival in a number of reportedstudies.
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What Do My Psa Test Results Mean
Once your test results are back, your healthcare provider will let you know if any additional testing is recommended. PSA levels can vary over time for several reasons unrelated to prostate cancer . So, if you have a borderline PSA, your provider may simply recommend another PSA test in six months or so.
Estimate Of Magnitude Of Net Benefit
Conclusions from decision analysis models, which are consistent with the findings of randomized trials and cohort studies, suggest that more aggressive screening strategies, particularly those that use a lower PSA threshold for biopsy than generally used in the United States, provide the greatest potential reduction in death from prostate cancer. However, these strategies are also associated with more false positives, more biopsies, and higher rates of overdiagnosis.24
Options for reducing the overdiagnosis rate include lowering the age at which to stop screening, extending the interval between screenings, and using higher PSA thresholds for biopsy. However, no strategy completely eliminates overdiagnosis. PSA-based screening for prostate cancer every 2 or 4 years instead of annually appears to provide a good trade-off between a reduction in overdiagnosis and a small reduction in mortality benefit.24
Although active surveillance may reduce exposure to the potential harms of active treatment, it may not be viewed favorably by some men who value definitive action, are concerned about repeat biopsies, or want to avoid a potential increase in metastatic cancer.
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Worried About Having A Dre
Its natural to feel worried or embarrassed about having tests, but some men find the idea of having a DRE upsetting. For example, if youve been sexually abused as a child or an adult, you might feel very upset about having this test. Theres no right or wrong way to feel about this, and it is your choice whether or not you have tests for prostate cancer.
It might be helpful to talk to a counsellor about your experience, thoughts and fears. Or you could contact a charity for people whove been sexually abused, such as the National Association for People Abused in Childhood or SurvivorsUK. If you do decide to have a DRE, explain your situation to your doctor as they can talk through the test with you and help to reassure you.
When I had the DRE I thought, For a few seconds of discomfort, I can live with it. Yeah its uncomfortable, but it could save your life. A personal experience
Psa Testing Of Asymptomatic Men
The role of PSA testing in the diagnostic work-up of men with symptoms and in follow-up of confirmed prostate cancer is well defined. Nevertheless, the use of PSA testing for prostate cancer screening is controversial because of the risk of overdiagnosis and overtreatment of tumours that would not cause harm in a mans lifetime.5,27 Potential harms include biopsy complications , and treatment side-effects that affect quality of life.5,27 These harms should be considered along with the potential benefit of PSA testing of asymptomatic men.
The result of the European Randomised Study of Screening for Prostate Cancer showed a relative risk reduction of 27% in prostate cancer mortality and 30% reduction in the incidence of metastatic disease in men aged 55-69 who were randomized to screening.27,37 The benefits of screening in the ERSPC were shown to be:
Although the serum PSA level serves as a risk factor for the presence of clinically significant prostate cancer, it has both a significant false positive and false negative rate for prostate cancer detection. PSA testing lacks sensitivity at lower ranges , and lacks specificity at higher ranges as elevations may be due to other causes .40 PSA values increase with age and there is currently no single cut-off value with a corresponding high sensitivity and specificity for prostate cancer, but rather a continuum for which it serves as an indicator for further investigations.41,42
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Who Should Get A Digital Rectal Exam
Not all medical institutions agree on when men should begin screening for prostate cancer or even if a DRE should be part of the screening.
To help detect prostate cancer in its early stages, the American Cancer Society recommends that men talk to their doctors about the benefits, risks, and limitations of prostate cancer screening before deciding whether to be tested.
For most men at average risk, discussions about screening begin at age 50. However, some doctors recommend that men at higher risk of prostate cancer — African-American men or men with a family history of prostate cancer — start screening earlier.
Population Observations Of Early Detection Incidence And Prostate Cancer Mortality
While digital rectal exam has been a staple of medical practice for many decades, prostate-specific antigen did notcome into common use until the late 1980s for the early diagnosis of prostatecancer. Following widespread dissemination of PSA testing, incidence rates rose abruptly. In a study of Medicarebeneficiaries, a first-time PSA test was associated with a 4.7% likelihood of aprostate cancer diagnosis within 3 months. Subsequent tests were associatedwith statistically significant lower rates of prostate cancer diagnosis.
In an examination of trends in prostate cancer detection and diagnosis among140,936 White and 15,662 African American men diagnosed with prostate cancerbetween 1973 and 1994 in the National Cancer Institute’s Surveillance, Epidemiology, and End Results database, substantial changes were foundbeginning in the late 1980s as use of PSA diffused through the United States age at diagnosis fell, stage of disease at diagnosisdecreased, and most tumors were noted to be moderately differentiated. ForAfrican American men, however, a larger proportion of tumors were poorlydifferentiated.
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