But what about men? Do they tend to have a preference? I’ve heard both sides of the camp. I’d love to hear from you in your comments here or on my Facebook page.
Here's a not uncommon scenario when I see some of my brand new male patients for a physical exam:
“So do you have any concerns you wanted addressed today?”
“My wife sees you, and she actually made me come in today. Otherwise, I wouldn’t be here. I don’t like doctors.”
“When is the last time you had physical?”
“Not sure. More than 10 years ago, I’d say”
“Wow, that is quite a while. You’re not afraid of us, are you?” I say with a smile. Mind you, I’m the least intimidating-appearing physician you’ll ever meet at 5 feet tall with a petite frame.
“Well, to be honest, I’m not looking forward to that prostate exam.”
“Oh, I see. You mean the rectal exam to feel the prostate surface?”
“Yes.”
“We don’t do it anymore.”
“What?! You meant I was dreading this visit for no reason this whole time?”
“Yes.”
It astounds me that many men are still unaware of this. Not unlike women who still believe that pap smears (tests for cervical cancer) are done annually (they’re not). If that is the only reason you dread the doctor, please fear no more. “Digital Rectal Exams” (or DRE) is no longer recommended as a routine screen, and I don’t know many up-to-date primary care physicians who still choose to do them. And neither is the blood PSA level (Prostate Specific Antigen).
Why don’t we screen for prostate cancer any longer? Some of you may be wondering why your doctor didn’t say anything about it and/or why your blood work didn’t include it. Read on for a synopsis of why this has now changed.
What is the Prostate?
The prostate is a gland only present in the male reproductive system, and functions to help produce the fluid that is released in the semen. The average normal prostate size is about the size of a golf ball. It sits right next to the rectum and below the bladder, hence causing obstruction to the urinary flow when the gland is enlarged; hence, producing such symptoms such as increased frequency and hesitancy.
With age, the prostate gland tends to enlarge for most men, and often reflects two major possibilities:
1. Benign prostatic hypertrophy (or BPH) which is a diffuse enlargement of the gland that is benign (not cancerous), and accounts for most elevated PSA’s.
2. Prostate cancer
I know the word “cancer” makes many of us cringe at the thought. But I’ll explain why it doesn’t typically cause doctors to blink an eye most of the time when it comes to the prostate.
What is the Prostate Specific Antigen (PSA)?
PSA is a protein that is released from the cells of the prostate gland. Therefore, the more prostate cells, then the higher the PSA level (such as in BPH or prostate cancer). But it’s important to remember that other benign factors can also increase the PSA level transiently:
· Prostatitis, which is inflammation or infection of the prostate
· Manual manipulation of the prostate (digital rectal exams, anal sex, recent ejaculation, recent biopsy of the prostate, anything that physically places pressure on the prostate gland)
· Urinary retention (holding it in or not being able to go)
These conditions only temporarily elevate the PSA. Once the condition has resolved, the PSA typically drops back to its baseline level. Therefore, even benign conditions can elevate the PSA.
But is routine PSA screening a beneficial tool for prostate cancer?
Of note, when we refer to a test as a “routine screen,” we are referring to men without any symptoms. The discussion in this article would be completely different if there are symptoms.
What is Prostate Cancer?
Prostate cancer is the most commonly diagnosed cancer in men, besides non-melanoma skin cancers. Yet it is the 6th cancer leading cause of death in men in the U.S. The risk of dying from prostate cancer is less than 3%.
Since the 1990’s, the PSA test was used as a presumed way to screen for prostate cancer, without a lot of research to support its use in this way. There were no studies to show that screening men actually decreased mortality. In medicine, screening tests are only recommended if they make a difference in the end. The thought is: so what if the PSA test detects prostate cancer, if it doesn’t actually save lives in the end? That is the crux of the question.
Two landmark studies involving PSA screening has since changed the way physicians practice:
1. European Randomized Study of Screening for Prostate Ca (ERSPC):
PSA screening was shown to decrease risk of mortality by 21% in those with cancer in this study. But in order to prevent 1 death from prostate cancer, 1410 men needed to be screened and 48 men treated. It also suggests that the only group of men who may benefit from screening are those between 55 and 69 years old.
2. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial:
This was a study of about 76,000 men that showed screening was associated with a 22% increase in prostate cancer diagnoses (not death) after 7 years of follow-up. Despite this and unlike the ERSPC study above, no difference in mortality was found in this study.
Furthermore, PSA testing can be potentially harmful. Routing screening may result in unnecessary testing, invasive biopsies, surgeries, and yield aggressive treatment complications (such as erectile dysfunction, problems with urination or bowel), that otherwise most men would never need if they weren’t tested in the first place. These consequences can diminish quality of life.
The U.S. Preventative Services Task Force (USPSTF), which is the leading organization that sets screening guidelines for practicing physicians, concluded in 2012 that the harm outweighs benefits in prostate cancer screening. And they recommend against routine PSA screening in all men, regardless of age. When choosing to be screened for prostate cancer, patients would be selecting a higher risk of morbidity (diminished quality of life) for a very small chance of improved mortality.
However, the USPSTF’s recommendation has been criticized by several other medical organizations who report a benefit in screening. And physicians are encouraged to individualize decisions based on each patient after reviewing the pros/cons for each person.
Risk Factors for Prostate Cancer
By far, the most common risk factor is age. Approximately 80% of those over the age of 65 will develop prostate cancer. But because the cancer is typically slow growing, most men with prostate cancer do not die from it. They die from other medical conditions, such as cardiovascular disease, which is the top cause of death in the U.S. for both men and wome
Here are other patient populations who are higher risk, and who may potentially benefit from screening:
· African Americans are 2 times more likely to die from prostate cancer.
· Those with a family history of prostate cancer in a first degree relative (parent or sibling)
· A diet high in fat
In summary, it is vital for you and your physician together to decide if the pros outweigh the potential cons when deciding on whether or not to screen you for prostate cancer. If you have any of these risk factors, make sure to mention them to your doctor. And now, after reading this, you will be equipped with the knowledge and latest information on this topic, in order to discuss it thoroughly with your doctor.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
Well, thanks again for listening to this episode of the House Call Doctor. If you have any future topic suggestions, you can email me at housecalldoctor@quickanddirtytips.com. Have a healthy week!
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