The harms are just as important as the benefits

I’m not sure I can say it any better than this:

Although 1 in 6 men (16.7%) will receive a diagnosis of prostate cancer in their lifetime, only 2.9% will eventually die of the disease.

That means that 97 out of 100 men who are diagnosed with prostate cancer die of something else. And this:

The proportion of men who are diagnosed with prostate cancer but never have associated clinical symptoms is difficult to estimate, but it may range from 23% to 66%.

In other words, many prostate cancers are slow-growing, and as many as two-thirds would have no effect on a man’s health or lifetime if left undiagnosed. Finally, this:

The small potential benefit of prostate cancer screening corresponds to preventing, at most, 1 death caused by prostate cancer per 1000 men screened after 11 years of follow-up.

The harms, on the other hand, are well-known. Men who get diagnosed with prostate cancer and who undergo a radical prostatectomy have an 11% increased risk for urinary incontinence and a 37% increased risk for erectile dysfunction.

All of this comes from the new American College of Physicians’ guidelines on screening for prostate cancer. They have two recommendations. First, they advise clinicians to inform men between the age of 50 and 69 years that the potential benefits for prostate cancer screening are limited and that the harms are substantial. Furthermore, they stress that screening should only occur in patients who express a clear preference for screening after being fully informed. Second, they recommend that clinicians not use a PSA test in average-risk men younger than 50 years, older than 69 years, or who are expected to live less than 10 to 15 years. In other words, the only men who should get a PSA are those age 50-69 years who have above-average risk and a life expectancy of 15 years or more.

This would seriously reduce the number of men who get screened, who have unnecessary surgery, and who suffer harms from such procedures. It is evidence based, thoughtful, and still allows for patient preferences. Nonetheless, I expect the cries of “death panels” to start soon.


UPDATE: The language is unclear in the guideline, but SEER statistics seem to state that 2.9% of all men will eventually die of prostate cancer.

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