Dr. Jacqueline Gerhart: Talk to Your Doctor About Prostate Testing
Madison, Wisconsin - UW Health Family Medicine physician Jacqueline Gerhart writes a column that usually appears weekly on madison.com and in the Wisconsin State Journal. Columns are re-published here with permission.
Dear Dr. Gerhart: I'm 60 years old, and my doc didn't do a rectal exam to check for prostate cancer at my last physical exam. The American Cancer Society recommends yearly rectal exams, so why didn't the doctor do one?
Dear Reader: Prostate cancer screening is one of the most confusing topics we have in primary care. The guidelines are frequently changing, and different national societies do not agree on the frequency or type of prostate screening.
I applaud you for asking, "Where's my rectal exam?" Usually when my patients find out they don't need a rectal exam, a sense of serenity and excitement washes over their face. I've even gotten high fives and hugs after revealing I'm not testing "down there" at this visit.
Routine prostate cancer screening has had two main components over the years: A blood test called a prostate-specific antigen (PSA) and a digital rectal exam – in which a health care provider uses a single, gloved finger to reach up the rectum to feel the prostate, which sits just in front of the rectum.
The digital rectal exam is difficult for multiple reasons. First, we can only feel a portion of the prostate. If there is a lump on part that we can't reach, we may not feel it. Second, it is often difficult to determine mild changes in size or symmetry of the prostate since we can't actually see the prostate. Third, there is no way to accurately measure the size of the prostate through rectal exam other than judgment. And, often practitioners disagree on whether a rectal exam is "normal" or "abnormal." So, our assessment is rather subjective.
When addressing my patients and their need for prostate screening I start by asking the following questions:
- Have you ever had a prostate problem in the past?
- Do you have a family history of prostate cancer?
- Have you had any changes in your urinary habits?
If they have had prostate problems in the past, are of African American descent or have a significant family history of prostate cancer, then those patients are in a different category. "Routine screening" no longer applies, because they may be at a higher risk for prostate cancer. In these cases, I often do a rectal exam, or a rectal exam along with a PSA.
For patients who answer "no" to any of the above questions, I then ask, "What have you heard about PSA testing and prostate screening?" Some people have heard that the PSA is a bad screening test (which is true). Others have heard that they need a yearly rectal exam and PSA blood test (which is often not true). The current "routine screening" guidelines by each society are:
- American Urologic Association: Patients aged 55-69 should be offered PSA testing, after discussing risks/benefits with their clinician.
- United States Preventive Task Force: Patients should not be routinely screened with PSA testing. Rectal exams have insufficient evidence to recommend for or against them.
- American Cancer Society: Patients can get a PSA with or without a rectal exam starting at age 50, but there is not sufficient evidence to show if benefits outweigh risks/harms.
- American College of Physicians: "Only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test. For most of these men, the harms will outweigh the benefits."
The bottom line for all of these recommendations: They are conflicting and confusing. Your options range from testing on regular intervals between ages 50 and 69, to no testing at all. It simply depends on your history, symptoms and preference.
Talk to your family physician or urologist regarding prostate cancer screening and your personal risk and benefits.
This column provides general health information and is not specific advice intended for any particular individual(s). It is not a professional medical opinion or a diagnosis. Always consult your personal health care provider about your concerns. No ongoing relationship of any sort (including but not limited to any form of professional relationship) is implied or offered by Dr. Gerhart to people submitting questions.
Date Published: 04/09/2014