Prostate cancer screening

Do you ever wonder how doctors come up with the myriad of recommendations that they give you at your yearly physical? Is it something they believe to be true simply because they have been doing it that way or is it a guideline developed by some health agency like the Centers for Disease Control and Prevention (CDC) or the United States Preventive Services Task Force (USPSTF)? I would hope providers are only suggesting evidence-based practices to their patients, but let’s just say physicians are not created nor trained equally.  

However, what happens when these recommendations are developed as a result of studies with an obvious lack of diversity, as in the case of the Prostate, Lung, Colorectal, and Ovarian (PLCO) study. Because of that study, the USPSTF now recommends against prostate cancer screenings using PSA, the prostate specific antigen, in all men. These new guidelines caused quite a bit of controversy and essentially caused all men to be placed in the same category when some are obviously at higher risks than others. 

The PLCO study was a large randomized trial that showed that men who underwent annual PSA testing along with a digital rectal exam had a higher incidence of prostate cancer than the control group but the death rate was the same for both groups. Therefore, there was no difference in mortality between those screened and not screened. Unnecessary procedures, anxiety, and morbidity such as incontinence and impotence were consequences for those men who would have otherwise not known of their cancer if they had not been screened. 

Located just in front of the rectum and between the bladder and the penis is the walnut-sized prostate gland.  The prostate produces secretions that help protect and maintain the sperm. Urine is released from the body via the urethra which runs from the bladder through the prostate to the penis. The unique location of the prostate is the reason why if it is enlarged, men have so many problems with urinary issues such as hesitancy, night awakenings to urinate, and occasional dribbling. 

The prostate produces a protein called PSA and this protein can be measured in the blood.  Elevations in PSA can be indicative of prostate cancer but it can also be associated with an enlarged prostate, called benign prostatic hypertrophy, BPH. Prostate enlargement affects essentially all men over the age of 50. There are numerous medications that help relieve symptoms caused by BPH. 

The FDA, Federal Drug and Administration, approved PSA as a screening test in 1994. Scientists and doctors were using it to screen for prostate cancer even before then, however. In the past, most doctors believed that PSA’s greater than 4.0 indicated cancer. Now we know that cancer can be present even with levels below 4.0 and the opposite is also true as mentioned above in the examples of the enlarged prostate. 

Black men are 60 percent more likely to be diagnosed with prostate cancer, more likely to have a higher tumor grade upon diagnosis, and they are more likely to be diagnosed at a younger age.  For those reasons alone is why there has been such an outcry against the USPSTF recommendations, particularly amongst individuals who care for African American men. There have been some genes identified in black men that increase their risk, but this gene is absent in the majority of black men with prostate cancer. More research is definitely needed in this area. 

Socioeconomic factors play a huge part in this cancer disparity. Black men are more likely to be uninsured or underinsured which then results in delays in screenings and treatment. It has also been shown that black patients often are not aware of the multitude of options available to them in regards to cancer care.   Education is another component that contributes a crucial dynamic within the outcomes paradigm of prostate cancer for black men. 

The American Cancer Society and other organizations agree that the discussion regarding prostate cancer screening begin at age 45 for black men. This early discussion allows the provider and patient to make informed decisions that are appropriate for that particular patient.  Disease burdens are different for certain racial groups and as a society, we must acknowledge that fact and fervently work to ascertain the reasons for such disparities. 

As a community, I encourage each of us to reconsider our beliefs as it relates to our roles in research. If there is no research, the deadly mysteries of cancer continues.

Yours in Service,

Denise Hooks-Anderson, M.D.

Assistant Professor

SLUCare Family Medicine

yourhealthmatters@stlamerican.com