"Dad, why should all men get checked for prostate cancer?" my 13-year-old son asked me recently. Not a question you get from most kids, but we were at a 5K race sponsored by a prostate cancer advocacy group, so the "go and get checked" message was prominent.
"Well … that's actually quite complicated," I told him. "Not all men should. Let's talk about it after the race."
As the runners — many of whose lives had been touched by prostate cancer — gathered on a beautiful crisp autumn morning, I looked at my budding teenager with AirPods in his ears and thought that children often hit on the most difficult questions.
In 2018, more than 160,000 American men will be diagnosed with prostate cancer. Fewer than a fifth of men with prostate cancer will die from it. Yet it still is the second-leading cause of cancer death in U.S. men (lung cancer is the deadliest), because it is so common.
Screening might seem to be a slam-dunk for prostate cancer, given that this cancer is common, curable in early stages, and usually slow-growing, leaving time to intervene.
Yet, the problem is that screening helps some men but can expose many to risks and even harms. The decision to screen is like any important decision in our lives — a matter of weighing risks against benefits. And to balance risks appropriately, one has to understand them.
"Dad don't wait for me. Run ahead," my son urged me, somewhat breathlessly. "We run together," I answered, matching my pace to his.
But as I was pondering how to answer his screening question, my son was accelerating.
How many men and women who were running with us, I thought, could have safely avoided the massive disruption in their lives that prostate cancer can cause?
As a surgeon who treats genitourinary cancers, every week I meet men who are newly diagnosed with prostate cancer. My advice ranges from, "this cancer requires no treatment," to, rarely, "we cannot cure you, but we can control this for many years to come."
In fact, the screening controversy stems from this fact that prostate cancer comes in so many different shades. The scenario that fuels enthusiasm for screening is as follows: A healthy man has a blood test and a physical exam to check for prostate cancer. The doctor finds something and sends him for a biopsy. It's cancer. The man is treated, without any notable side effects, and his life is saved.
Yet, this isn't what usually happens, for a number of reasons:
Thankfully, overdiagnosis and overtreatment are coming into increasingly better focus in the prostate cancer field, with two main strategies:
A number of medical organizations have proposed various screening guidelines, and the differences reflect the contrasts in opinion on balancing risks and benefits. The guidelines largely agree that men 70 years and older are very unlikely to benefit from screening but may be harmed by it. Another point of agreement: the importance of shared decision-making between physicians and patients. Before any screening, patients should understand what's involved.
Minimizing treatment of low-risk prostate cancer is equally important. Active surveillance — where men are not treated but are carefully monitored for disease progression — is a critical strategy to avoid unnecessary risks. Though I am a surgeon, some of my most satisfying patient encounters are when I can tell a man that his best next step is to do less rather than more.
"Dad, I smoked you!" my son yelled as I crossed the finish line, some time after he had pulled ahead.
At the next race, I hope I'm in better shape and can keep ahead of my son. But even more, I hope the message at such events becomes a bit more nuanced.
"Screening is complicated. Get educated, then talk to your doctor," would be a better public health message. It is just too easy to fall behind without proper preparation.