HEA 3060 Module 2 Prostate Cancer Screening Paper: The PSA Decision for Men 55 to 69 Example

One Life Saved, Many Men Treated: Weighing the PSA Test at Fifty-Eight

Student Name

B.S. in Health Studies, Thomas Edison State University

HEA-3060: Men's Health

Mentor Name

Month Day, Year

One Life Saved, Many Men Treated: Weighing the PSA Test at Fifty-Eight

Introduction

Prostate cancer is the most commonly diagnosed cancer in American men apart from skin cancer, and it is a leading cause of cancer death. Yet many prostate cancers progress so slowly that the man dies of something else first, never knowing they were there. A blood test for prostate-specific antigen, or PSA, can find cancers early, but it also finds many that would never have mattered. Whether screening does more good than harm has been argued for decades. This paper explains the main evidence and how one man might use it.

The Man

Calvin is invented for this paper. He is 58, a mechanic for a county bus depot, married with three grown children, and lives in Willingboro. His older brother was diagnosed with prostate cancer at 63 and had surgery, and he urges Calvin to be tested. Calvin has never had a PSA test. He is healthy apart from mild high blood pressure and wants to know whether the test is worth it.

The European Trial

Schröder et al. (2009) reported the European screening study, known as ERSPC, in which men aged 55 to 69 in seven countries were randomly assigned to PSA screening, usually every four years, or to no screening. Nine years into follow-up (median), the screened group had about one fifth fewer deaths from prostate cancer. In absolute terms, the authors estimated that for each prostate cancer death avoided, 1,410 men had to be screened and 48 extra cancers had to be treated. Screening also led to many more diagnoses, a large share of them low-risk cancers.

The American Trial

Andriole et al. (2009) reported the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial in the United States, in which about 76,000 men aged 55 to 74 were assigned to annual PSA testing and digital rectal examination or to usual care. After seven to ten years, the death rate from prostate cancer was very low and did not differ significantly between groups. A major limitation was contamination: a large share of the usual care group got PSA tests outside the study, so in practice the comparison was heavy screening against lighter screening, not screening against none.

The Recommendation

For men aged 55 to 69, the Task Force concluded that PSA screening offers a small potential benefit of reducing the chance of death from prostate cancer, along with potential harms including false-positive results, biopsy complications, overdiagnosis and the effects of treatment, such as erectile dysfunction and urinary incontinence (US Preventive Services Task Force, 2018). It recommended that the decision be individual and that clinicians discuss benefits and harms with each man, a grade C recommendation. For men 70 and older, it recommended against screening. The Task Force pointed to higher risk among Black men and among men whose relatives had the disease, though evidence was limited on whether screening benefits them differently.

Benefits and Harms in Plain Numbers

Calvin can think about the decision in terms of what might happen to a large group of men like him. Most screened men will never be diagnosed with prostate cancer. Some will have a raised PSA that leads to a biopsy, which may cause pain, bleeding or infection. Some will be diagnosed with a cancer that would never have harmed them, and if treated with surgery or radiation, some of these men will have lasting problems with erections or bladder control. A small number will avoid death from prostate cancer because their cancer was found early.

Active Surveillance

One change since the trials has reduced harm. Many men diagnosed with low-risk prostate cancer are now offered active surveillance, in which the cancer is monitored with regular PSA tests, examinations and sometimes repeat biopsies or imaging, and treatment begins only if it shows signs of progressing. This approach lets men avoid the side effects of treatment for cancers that stay quiet.

Race and Family History

Calvin has two risk factors. Black men in the United States are more likely to be diagnosed with prostate cancer and more likely to die from it than white men, for reasons that include differences in access to care and possibly biology. His brother's diagnosis also raises his risk. Both factors may make the potential benefit of screening larger for him, though trials included few Black men.

Calvin's Decision

Calvin talked with his primary care clinician, who explained the numbers and active surveillance. Given his brother's cancer and his own race, he decided to be screened and to ask about surveillance if a low-risk cancer were found. His wife came to the visit, and he said that having the numbers made him feel in control of the choice.

Talking About the Decision

Shared decision making means that the clinician explains the options and their likely results and the man brings his values. Decision aids, short printed or online tools that show benefits and harms in pictures and numbers, help men understand the trade-off and feel less conflicted about their choice. For a man like Calvin, a decision aid that shows outcomes for 1,000 men like him could make the numbers easier to grasp than percentages.

Limits

The trials began decades ago, before MRI and active surveillance were common. Few Black men were included. Calvin's story is invented to illustrate shared decision making, not to recommend a choice for any reader.

Conclusion

PSA screening offers men aged 55 to 69 a small chance of avoiding death from prostate cancer and a larger chance of diagnosis and treatment they may not need. The European and American trials disagree in part because of how they were run, and the Task Force leaves the decision to each man. For Calvin, family history and race tipped the balance toward screening, and active surveillance reduced his fear of overtreatment.

References

Andriole, G. L., Crawford, E. D., Grubb, R. L., Buys, S. S., Chia, D., Church, T. R., Fouad, M. N., Gelmann, E. P., Kvale, P. A., Reding, D. J., Weissfeld, J. L., Yokochi, L. A., O'Brien, B., Clapp, J. D., Rathmell, J. M., Riley, T. L., Hayes, R. B., Kramer, B. S., Izmirlian, G., . . . Berg, C. D. (2009). Mortality results from a randomized prostate-cancer screening trial. New England Journal of Medicine, 360(13), 1310-1319. https://doi.org/10.1056/NEJMoa0810696

Schröder, F. H., Hugosson, J., Roobol, M. J., Tammela, T. L. J., Ciatto, S., Nelen, V., Kwiatkowski, M., Lujan, M., Lilja, H., Zappa, M., Denis, L. J., Recker, F., Berenguer, A., Määttänen, L., Bangma, C. H., Aus, G., Villers, A., Rebillard, X., van der Kwast, T., . . . Auvinen, A. (2009). Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine, 360(13), 1320-1328. https://doi.org/10.1056/NEJMoa0810084

US Preventive Services Task Force. (2018). Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA, 319(18), 1901-1913. https://doi.org/10.1001/jama.2018.3710