The first reports from two long-awaited large, randomized trials designed to provide answers about the effectiveness of prostate cancer screening have been published in the New England Journal of Medicine. Below are comments from Otis W. Brawley, M.D., American Cancer Society chief medical officer.
“These early results from two major trials suggest that if prostate cancer screening is beneficial, the benefit is small in terms of lives saved. For several years, many experts had anticipated these studies would show a small number of men will benefit from prostate screening, but a large number of men will be treated unnecessarily. And that’s what these studies show.
“These data show that what the American Cancer Society and other organizations have been recommending for many years still applies: that men at average risk should decide whether or not to be screened based on their own concerns and situation and after discussing the benefits and limitations of screening with their doctor. These recommendations are unlikely to change until we have adequate long-term data. These early reports are helpful, but longer follow up over the next decade or more is needed before we can fully understand the benefits of routine screening of men at average risk. As with any type of cancer screening, the question is not as simple as: ‘does prostate cancer screening work?’ What we need to know is: what are benefits of prostate cancer screening and are they large enough to outweigh the harms associated with it. And despite the release of this early data, we still cannot say whether the benefits outweigh the risk.
“What is perhaps most important here is that people are beginning to get answers to the question of whether we should be screening men at average risk. For many years, people who suggested this was still an open question have been criticized as not supporting anti-cancer efforts. In some respects, over the last 20 years, many have been eager to promote widespread screening based on the assumption that finding cancer early is beneficial. Now as these reports have begun to come out, we see that the results may not be as favorable as many had hoped or even anticipated.
“I do have an important concern that if this information is not interpreted appropriately by doctors, those covering the news, and by the general public, we can do some harm. There is a group of men who should be getting screened but who, after hearing this week’s news, may begin to shy away from testing. There is no debate that men who have urinary symptoms, such as frequent or difficult urination, a weak stream, etc., ought to be getting exams including PSA tests. That is not screening; screening is testing asymptomatic men for signs of cancer. Men who have symptoms should be getting tests.
“Another important question is: what do we say to men who have just been diagnosed with prostate cancer and are now deciding whether to undergo treatment. The new reports are important to include in the discussions they need to be having with their doctors before deciding what treatment, if any, is best for them.
“More than ten years ago, the American Cancer Society came out against routine or mass screening and instead endorsed shared decision making, where a man has a conversation with a health care professional to discuss the pros and cons as well as his individual preferences. We are gratified to see that shared decision making is the recommendation that is called for in the editorial that accompanies these reports. The fact that Dr. Barry in his editorial has reaffirmed these recommendations is a clear signal that we and other organizations that advocate shared decision-making have been on the right track. Almost all organizations that make screening recommendations have recognized that whether screening works is legitimate question. Some organizations actually now recommend against screening. Despite that, there is still widespread misinterpretation or misapplication of our guidelines. In fact, a discussion in this same issue of the New England Journal of Medicine misportrays the American Cancer Society guideline, saying the Society recommends screening. We do not recommend screening for men at average risk; we recommend shared decision making.
“Clearly those who have advocated for widespread screening and treatment for prostate cancer have done so because they have felt it was the right thing to do, and felt strongly they were helping people. At the same time, the call for shared decision making by professional organizations, including the ACS, has often been ignored because of an understandable belief that finding cancer early and treating it was the best thing to do. There’s a long term lesson to be learned here about being faithful to the science, and about tolerating diverse opinions and having discussions based on the scientific evidence before making recommendations prematurely.”
For more information, please see “Can Prostate Cancer Be Detected Early”