Let’s address a conversation that I’ve had with my male patients given some new recommendations about prostate cancer and screening. When adult men come in for their annual physical exams, especially those older than 50, most are prepared to have the uncomfortable and unpleasant experience of a rectal and prostate exam.
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It’s as expected as a pap smear and breast exam are for most adult women. However, recently, there is a recommendation to stop performing prostate exams, which has been confusing for all us all.
The U.S. Preventive Services Task Force (USPSTF) is the nation’s most knowledgeable group of medical experts who put together what the official recommendations for health maintenance should be. In the past, the recommendation was to screen all men at 50 and older (45 and older for Black men or those with a family history of prostate cancer), have both a digital rectal exam to examine the prostate and a blood test called the prostate specific antigen (PSA).
It was thought that this was the best way to screen and find early prostate cancers. For a long time it was a debatable topic. However, in November 2012, the USPSTF’s official recommendation was made against yearly DREs and PSAs. We were told NOT to do them. Research has found that it has caused more harm than good.
The rationale is the majority of all men by the age of 80 or 90 will have some form of prostate cancer. It is also true that the cancer will likely be benign or non-life threatening. So the question was asked if it was worth finding a non-life threatening problem earlier versus later when it wouldn’t save lives.
The other part of the issue was what I mentioned earlier – the idea of harm. Harm is caused, potentially, in doing the exam (it’s not a comfortable one to have), finding something abnormal or having an abnormal PSA level, and having to “chase it” down. PSAs can be elevated for reasons other than cancer, such as having an enlarged prostate or bacterial infection. But once an elevated PSA is found, it’s hard to convince anyone that you shouldn’t look further and rule out cancer.
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Then comes the more difficult part of testing, and that’s the prostate biopsy. If you’ve had a prostate biopsy or know someone who’s been through it, you know it’s one of the most painful procedures to endure. It’s also not inexpensive. Because of these issues and more details from medical research, the USPSTF experts gave it a “D” recommendation. They found at least fair evidence that (the service) is ineffective or that harms outweigh benefits.”*
Then there’s the flip side: What do we do?
Do we ignore the prostate and not screen at all? What I do in my practice, for better or for worse, is have the conversation. I explain the situation above and ask the patient about his symptoms or lack thereof. I ask if he has any problem with urination, blood in the urine, change or straining in flow or getting up more than twice a night to urinate. I ask whether he has any relatives with prostate cancer.
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If all answers are no, I make sure there’s at least one normal DRE and PSA in his history, and, if this is the case, we don’t do them. If the patient is nervous and chooses to have the screenings done after having the conversation, that is his choice.
If there are any yes answers to the above questions, I generally will check a PSA level, and if it’s normal, I skip the DRE. I’m sure other doctors are doing different things, but, ultimately, the patient making an educated decision is always the best route to take.
Dr. C. Nicole Swiner is currently a Family Physician in Durham, NC, and has worked in a clinic owned by the University of North Carolina since 2007, after completing her residency training there. She received her undergraduate degree from Duke University. She also serves as an Associate Professor at UNC and has interests in minority health, gynecology, and pediatrics. Dr. Swiner is the author of “How To Avoid The Superwoman Complex”.
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