Gen. Norman Schwarzkopf is on the TV circuit talking up his latest cause: Getting all men over 50 tested for prostate cancer. Schwarzkopf was himself diagnosed with this disease five years ago, and credits prostate surgery with saving his life. While Schwarzkopf’s efforts are well intentioned, unfortunately, they are also misguided.
In a recent Today Show interview on NBC, Schwarzkopf went so far as to say that with universal screening, prostate cancer would be virtually preventable, and that with early detection, the side effects of treatment were minimal or nonexistent. However, sweeping statements and exuberant optimism about wiping out prostate cancer misrepresent the realities of the disease, and of its detection and treatment.
Indeed Schwarzkopf’s public enthusiasm for widespread prostate cancer testing masks an anguished debate in the medical community about exactly which men should be tested for prostate cancer. This debate intensified when a simple blood test to detect prostate cancer — the prostate specific antigen, or PSA, test — became widely available about a dozen years ago.
The argument that detecting cancer early will improve the chances of survival is a basic, intuitive one. But sometimes this “truism” is more apparent than real. For example, it can be legitimately argued that colon cancer is largely preventable by screening. Screening with a fecal occult blood test or tests like a colonoscopy can detect polyps or cancer. When detected, these polyps or cancers can be surgically removed quickly and efficiently, essentially without risk or negative side effects.
For prostate cancer, unfortunately, the story is more complex.
Prostate cancer — although not necessarily a life- or health-threatening type — is extremely common. The current estimate is that at least 11 million American men have prostate cancer in some form. Only a fraction have been diagnosed. Each year, about 40,000 men die of prostate cancer in this country. Signs of prostate cancer are found during the autopsies of almost all men age 90 or over who die of other causes; the figure is about 40 percent for men aged 40 to 49. In other words, there is a large discrepancy between the number of men who have some form of prostate cancer and the number of men whose life or health is threatened by it. This fact is critical when it comes to evaluating the need for mass screening and the options for treatment.
Given the above reality, universal screening of all men over age 50 will pick up substantial numbers who have a “dormant” prostate cancer — meaning they have a form of the disease that will never progress to a life-threatening stage. These men with dormant prostate cancer then hazard the discomfort, risk and expense of follow-up evaluations such as biopsies, as well as the more significant risks associated with hormonal, radiation and especially surgical treatment, if cancer is detected. Results of biopsy specimen analysis can sometimes indicate if a cancer is likely to be aggressive, but this is far from certain.
Contrary to what Schwarzkopf says in his interviews promoting prostate screening, a substantial number of men undergoing treatment for prostate cancer still do suffer from incontinence and impotence, at least temporarily, despite the advances in what has been called “nerve sparing” surgery.
Is prostate cancer screening good public-health practice? The answer requires more than the TV soundbite opportunity given to Schwarzkopf. For men with a family history of prostate cancer, regular screening after 50 may be desirable. Also, black Americans have a higher rate of prostate cancer than whites, so they are more likely to benefit from screening. But there is no medical consensus to support a call for universal prostate cancer screening, primarily because there is no evidence at hand that early or universal prostate screening saves lives.
The lack of enthusiasm for Schwarzkopf’s universal screening recommendation was evident this week in San Diego when the American Medical Association decided against adopting guidelines for early prostate cancer detection. Those voting against this recommendation cited the lack of evidence-based benefit. The AMA decided to refer the guideline proposal to its board of trustees for additional study.
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