Saturday, April 01, 2006

Prostate cancer screening: What are your options?

Prostate cancer screening: What are your options?

Prostate cancer is one of the most common forms of cancer in men. And it's one of the leading causes of cancer death in men, second only to lung cancer. Fortunately, several simple and relatively painless screening tests — for example, the prostate-specific antigen (PSA) test — can help reveal whether you have prostate cancer.

However, significant controversies exist regarding whether to screen for prostate cancer. Educate yourself on the pros and cons of prostate cancer screening so that you can better talk to your doctor about choosing the approach that's right for you.

Two tests can help identify a problem
The prostate gland, found only in men, is about the size of a walnut and is located beneath the bladder.

The two most widely used tests to check for cancer in this gland are the digital rectal exam (DRE) and the prostate-specific antigen (PSA) test.

Digital rectal exam (DRE)
Because of the prostate's location, your doctor can feel the back surface of your prostate through your rectum. During a DRE, the doctor inserts a gloved finger into the rectum and feels the gland. Some prostate cancers grow in an area that the doctor can feel. Potential tumors may feel like lumps or hard spots.

Prostate-specific antigen test (PSA)
PSA is a substance produced by the prostate gland. Small amounts are released into your bloodstream. Testing the amount of PSA circulating in your bloodstream can help your doctor identify many prostate-related problems. To draw blood for the test, a nurse or technician cleans the skin over a vein, usually in the crook of your elbow, inserts a needle, and collects blood into a syringe or vial.

Adult men typically have PSA levels below 4 nanograms per milliliter (ng/mL) of blood. When interpreting a PSA value, however, your doctor considers a number of factors that may affect your PSA level and help determine a normal range for you. Such factors include your age, the size of your prostate and the relative change in the PSA level over time.

Understanding your PSA levels
Normal PSA range
Normal PSA range
40 and younger
0 to 2.0 ng/mL
0 to 4.5 ng/mL
0 to 2.4 ng/mL
0 to 5.3 ng/mL
0 to 2.8 ng/mL
0 to 6.2 ng/mL
0 to 3.3 ng/mL
80 and older
0 to 7.2 ng/mL
0 to 3.8 ng/mL

Some doctors use this age-adjusted scale to determine if your PSA level is within a normal range. Your PSA level rises naturally as you age, and the upper limits of the normal range also increase with age. For instance, the upper limit for a 55-year-old man is 3.3 nanograms per milliliter (ng/mL), higher than that of a 40-year-old man (2.0 ng/mL). Race also affects PSA. Black men tend to have slightly greater PSA levels than do white men. Talk to your doctor about what your level means for you.

Results between 4 and 10 are borderline high and suggest a one-in-four chance of prostate cancer. A number greater than 10 is high and suggests a chance of prostate cancer at more than 67 percent. The higher the number, the more likely the presence of prostate cancer — but high PSA values can also occur in benign conditions such as infection of the prostate gland, interrupted blood flow to the gland, or benign enlargement of the prostate, which is common in men as they age.

On the other hand, just because a PSA level is below 4 doesn't mean you're cancer-free. In a 2004 study, researchers took samples (biopsies) of prostate tissue from nearly 3,000 men with a PSA level of 4 or below; 449 of the men were found to have prostate cancer.

All of these variables make it key that PSA levels are interpreted by a doctor experienced in dealing with prostate disease.

Variations of the PSA test
Some tests measure specific aspects of PSA in your blood, which may help your doctor decide whether to do further testing, such as biopsy, to assess your cancer risk. It's unclear what role these tests play in prostate cancer prevention. If your standard PSA test results come back abnormal, the American Cancer Society recommends that you discuss the following with your doctor:

Percent-free PSA. One form of PSA attaches to blood proteins. The other circulates freely, or unattached. This test measures how much PSA circulates freely, compared with your total PSA. Men with prostate cancer have lesser amounts of free PSA than do men without prostate cancer.

PSA velocity. This test measures how fast your PSA level changes over time. If it rises faster than 0.75 ng/mL each year — for example a rise from 2 to 3.6 ng/mL over the course of two years — it may suggest cancer, even if your total PSA isn't particularly high.

PSA density. Your doctor may use this test if you have a large prostate gland. A transrectal ultrasound — a small device inserted in your rectum that generates sound waves to make pictures of the prostate on a video monitor — helps your doctor judge the size of the prostate. The doctor then divides the PSA number by the prostate volume. A greater number means an increased chance of cancer.

Simple tests, not-so-simple decision
You might think that prostate screening should be a normal part of your health checkups as you reach middle age or older. But screening for prostate cancer is controversial and major health organizations disagree on who needs prostate screening tests and how often. Here are some reasons for and against screening with PSA:

The good side of PSA testing

Earlier detection. Regular PSA screening can help identify prostate cancer before you notice any symptoms, when it likely still remains confined to the prostate (localized). Localized prostate cancer is easier to treat than is cancer that's spread to other organs. Once prostate cancer spreads, your chance of long-term survival is considerably less.

Something is helping. The number of prostate cancer-related deaths has dropped noticeably since the introduction of the PSA test. This trend suggests that PSA testing may help save lives.
Keeping tabs. The PSA test is certainly a useful monitoring tool once you know that you have prostate cancer. After the diagnosis, PSA testing can be used to monitor the cancer's progression, as well as its response to treatment.

The not-so-good side of PSA testing
Isn't specific. The PSA test can't distinguish between cancer and other prostate diseases such as prostate inflammation and a form of prostate swelling called benign prostatic hyperplasia, which also increase PSA levels. More than 70 percent of men with a PSA level between 4 and 10 don't have prostate cancer. So, many men with a high PSA may go through needless worry and costly medical procedures, including biopsy, to find out they don't really have cancer.

Medications can hide cancer. A medication called finasteride, found in the hair loss treatment Propecia, and a benign prostatic hyperplasia treatment, Proscar, can reduce your PSA level, even if you have prostate cancer.

Needless efforts. PSA testing may cause you to become aware of a cancer that never would have caused health problems. For example, nearly 10 percent of men age 65 and older have a small prostate cancer that's not causing any symptoms. The treatments to remove such tumors may cause impotence and incontinence, resulting in a decreased quality of life. But it's understandably difficult for a man to turn down these treatments when he knows he has a tumor.

"If you're an older man or you have poor general health and don't expect to live another 10 years, you may want to avoid prostate cancer screening," adds Donald Novicki, M.D., a urologist at Mayo Clinic, Scottsdale, Ariz. "You likely wouldn't benefit from treating a prostate cancer that's causing no symptoms."

May not really help. Health experts haven't yet proved with certainty that PSA testing reduces prostate cancer deaths.

Varying viewpoints: What are the recommendations?
The American Urological Association encourages men in good health to have annual PSA testing starting at age 50, or at age 40 if they're in high-risk groups, such as black men or those with a father, brother or son with the disease. The American Cancer Society, on the other hand, recommends that doctors offer the tests to men age 50 and older who expect to live another 10 years, and test men at high risk if they're age 45 and older.

Both groups also suggest that a DRE be done in conjunction with the PSA test. Though the DRE doesn't help find prostate cancer as well as does the PSA test, it can sometimes help find cancers in men with normal PSA levels. The Centers for Disease Control and Prevention doesn't recommend any routine prostate cancer screening.

Make an informed decision
Given the pros and cons of screening, it's best to make an informed decision with the help of your doctor's input. When you discuss the screenings, consider:
Your age and general health. The longer you're likely to live, the more reason to consider screening.

Your risk factors for prostate cancer, such as your race and family history
What further steps you'd be willing to take if your PSA test results do come back elevated, given the side effects such steps may introduce.

"It's helpful if you understand what prostate cancer screening involves, how it works and what information it provides," says Dr. Novicki. "Based on that information, make an informed decision as to whether you want to pursue screening."
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