Mayo Clinic Department of Urology perspective on prostate cancer screening

Balancing risks and benefits

Screening for prostate cancer is a complex and ultimately personal decision — it positions the hopeful prevention of prostate cancer death and morbidity against the possibility of treating an insignificant tumor. That said, most experts agree that prostate cancer is a serious disease and that screening is rather straightforward and detects high-risk prostate cancer.

The debate about prostate cancer screening centers around the fact that screening inevitably results in diagnosing some patients with indolent tumors that may never have become clinically significant. The ideal cancer-screening test would be a test that:

• Is inexpensive and easy to perform
• Detects clinically significant cancers with high sensitivity
• Fails to detect slow-growing, indolent tumors

Unfortunately, such a test isn't available today. This means that practitioners must rely on the best available options: PSA screening, digital rectal examinations and prostate biopsies.

It is important to recognize that the benefits of screening are critically tied to downstream factors such as treatment success and morbidity. The identification of a slow-growing prostate cancer should not be viewed as a failure of prostate cancer screening. Rather, it should represent an opportunity to discuss appropriate treatment options and select the right management approach for each patient.

Active surveillance has emerged as a preferred treatment option for many patients who are diagnosed with low-risk prostate cancer. For men who need treatment, advances are continuing to reduce the morbidity associated with surgery and other interventions.

Prostate cancer surveillance, including the sensible use of the PSA test, reduces the morbidity and mortality associated with this disease. What remains to be determined is how often and at what time such screening needs to be performed to maximize its effectiveness and minimize adverse effects.

Individualized screening approach

The Department of Urology at Mayo Clinic recommends an individualized, multifactorial approach to determining whether or not to screen a particular patient for prostate cancer. This approach, which should begin at age 40, incorporates an individual patient's risk of developing prostate cancer, a comprehensive physical examination, consideration of existing medical comorbidities, and a discussion regarding the benefits and potential risks of screening.

When determining whether to screen:

• Discuss the pros and cons of screening with the patient
• Conduct a physical exam, staying alert for comorbidities that can affect PSA score
• Take a comprehensive family medical history, noting previous biopsy history of the patient and his family members
• Consider the patient's age, recognizing the age-related increase in cancer risk
• Consider the patient's ethnic background, noting that African-American men have the highest risk of prostate cancer

Points to remember

• The purpose of prostate cancer screening with the PSA test is to detect prostate cancer when it is localized and therefore most treatable.
• Prostate cancer screening is controversial because no trials have conclusively demonstrated that the benefits of screening outweigh its risks.
• The majority of prostate cancers detected with screening are low risk and not immediately life-threatening.
• While prostate cancer screening identifies most prostate cancers, it does not discriminate between high-risk, life-threatening tumors and low-risk, indolent tumors.
• The death rate from prostate cancer has consistently declined approximately 4 percent a year since prostate cancer screening became commonplace.