DEAR DR. ROACH: A very healthy male friend in his upper 50s has to make a decision whether to accept or decline his very aggressive urologist’s decision to do a biopsy of his prostate. It seems that the only thing prompting this decision is a recent prostate-specific antigen (PSA) reading of 4 ng/mL, which has actually fluctuated a bit between 2-4 ng/mL over the past two years. His doctor states that at his age, it should be under 3 ng/mL.
The physician’s attitude is almost dismissive of my very knowledgeable friend’s concerns about jumping into a biopsy when he is extremely healthy, has no symptoms, and has no family history. So, as a compromise, he suggested that he’d come back in three to four months for another reading and see how things progress. The doctor’s response essentially was that my friend can do what he wants, but the doctor emphasized that this is serious and that he needs a biopsy.
We both recently read a review of the literature on prostate cancer (regarding diagnosis and treatments) by the National Library of Medicine. It stated that the recommendations for screening for prostate cancer using a PSA test are unclear! They also seem to say that early detection and resultant post-screening treatments can lead to overdiagnosing, unnecessary biopsies (with sometimes serious side effects), and the overtreatment of patients. — N.C.
ANSWER: You are quite right that the optimal strategy for screening for prostate cancer is unclear. Making the right personal decision requires a good understanding of the risks and benefits of testing, as well as the spectrum of aggressiveness of the prostate cancer. Remember, screening always means that there are no symptoms present.
There are a few men who can develop an aggressive form of prostate cancer that grows very quickly. Unfortunately, it is hard to catch most of these cancers because they grow so quickly. You have to be really lucky to get your screening test while the cancer is big enough to be detected and hasn’t yet spread.
There are many men who get a very slow-growing, almost indolent form of prostate cancer. This kind of cancer is destined to never bother most men who get it, and the majority will die of something else before they ever know they had it (unless they get a screening test). Treatment of this type of prostate cancer is unnecessary since it will never cause problems.
Finally, there is a group of men who have prostate cancer that can be detected by screening, hopefully in time to prevent the cancer from spreading. These are the cancers we want to find with screenings, as treating these men effectively saves lives. However, there are far fewer of these cancers than there are of the indolent-type of cancers.
The fact that his PSA level has been stable for two years argues against an aggressive cancer, but it isn’t definitive. Men can have prostate cancer with a PSA of 2 or have benign prostate disease with a PSA of 10, but usually, the higher the PSA, the greater the likelihood of cancer. However, your friend’s risk with a stable PSA level under 4 is small.
The most important time to be cautious in suspected prostate cancer is when the diagnosis has been made and the patient is deciding on treatment. His urologist would have much more information available after a biopsy, including pathology and genetic testing.
It bothers me that the urologist is belittling your friend’s reasonable concerns. This situation calls for respect, discussion and understanding — not an ultimatum.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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