Michael J. Whalen, MD, discusses the newly updated prostate screening guidelines set forth by the U.S. Preventative Services Task Force. The new recommendations advise a shared decision making process between patients and their providers, based on developments in screening and improved knowledge of the slow-growing nature of prostate cancer.
Dr. Whalen also explains why the traditional methods of screening, diagnosing and treating prostate cancer were reevaluated, particularly in terms of preserving men's quality of life.
Selected Podcast
What the New Prostate Screening Guidelines Mean for Men’s Health
Featured Speaker:
Learn more about Michael J.Whalen, MD
Michael J. Whalen, MD
Michael J. Whalen, MD is Assistant Professor of Urology at the George Washington University School of Medicine & Health Science and a member of the medical staff at The George Washington University Hospital.Learn more about Michael J.Whalen, MD
Transcription:
What the New Prostate Screening Guidelines Mean for Men’s Health
Dr. Mike Smith (Host): Welcome to GW Hospital Health Cast. I’m Dr. Mike Smith. The US Preventative Service Task Force recently updated its position on prostate cancer screening to a Grade C recommendation in favor of what they called “shared decision making” between patients and their providers. My guest, Dr. Michael Whalen, will explain what this means for men. Dr. Michael Whalen is a Urologic Oncologist and a member of the medical staff at the George Washington University Hospital. Dr. Whalen, welcome to the show.
Dr. Michael Whalen (Guest): Thanks for having me.
Dr. Smith: Let’s first talk about prostate cancer and prostate cancer screening and at least how we used to do that in the past before this update. Why don’t you give us a nice summary?
Dr. Whalen: Sure. Prostate cancer screening consists of a couple of things. One is a blood test known as a PSA or prostate specific antigen, which is obtained at the doctor’s office as part of regular laboratory work. The blood test is used in combination with what we call a digital rectal exam or manual finger examination of the prostate through the rectum. Those two tests are taken together to assess a man’s risk of having prostate cancer. Prostate cancer is a very common disease. It’s found in about one in six or seven Caucasian men and about one in five African American men and is one of the most common cancers that affects men in this country.
The PSA blood test is interpreted by the Urologist to determine how likely a man is to have prostate cancer. There’s no real normal value, but the interpretation is made with the patient to guide them toward the next steps in the evaluation, which may consist of other blood testing or imaging techniques or even moving on to a prostate biopsy.
Dr. Smith: Got you. When you look at the current way of doing this, then – you have the physical exam, and then you have the PSA blood test – how good of a screen was this process, then, for diagnosing prostate cancer?
Dr. Whalen: That’s a great question. The PSA blood test – truth be told – was initially used to detect any recurrent cancer after men had been treated with surgery to remove the prostate. You may imagine if the prostate is removed from the body, then that blood test basically should be zero. It shouldn’t show any of this enzyme, which is the substrate that we’re looking for with the blood test. The test was appropriated to be used as a screening tool – and in that respect, it doesn’t perform so well. In fact, it detects a lot of false positives because it’s not a specific test. We say it’s sensitive because it picks up a lot of men, but it’s not specific, meaning it doesn’t hone in and target specifically men who have prostate cancer.
If the PSA is elevated, it could mean that there is a tumor in the prostate or prostate cancer, but it could also be elevated for a few other reasons. One can be inflammation or infection of the prostate. Two, even recent sexual activity within about 48 to 72 hours, and three, benign enlargement of the prostate, which is something that occurs as men age and is responsible for a lot of urinary symptoms that older men experience. One thing that I tell patients is that the PSA is sensitive, but not specific, and in fact, casts a wide net and catches some dolphins in with the tuna. We don’t want to catch the dolphins. We only want to catch the tuna.
Dr. Smith: Right, right.
Dr. Whalen: These days, there’s more specific blood tests that we can do to determine a man’s risk of having a potentially aggressive prostate cancer rather than just low-grade prostate cancer. One thing to keep in mind is that unlike some other cancers that affect the people in this country like pancreatic cancer or even lung cancer – which are very rapidly growing and can be fatal – prostate cancer is often a slow-growing disease and may even be able to be watched rather than treated. There’s a current movement toward less is more in understanding that not all men that are diagnosed with prostate cancer have to be treated. In addition, there are more sophisticated blood tests that can stratify men into risk categories that may need to be treated and may be able to be watched.
Dr. Smith: Okay, and so is this then what led – with the idea that the PSA itself is sensitive where it tells you there’s something going on, but not specific to cancer – is this why then the US Preventative Service Task Force wanted to look at this and maybe reevaluate the screening process for prostate cancer.
Dr. Whalen: Exactly. In the past, the pendulum swung to more aggressive treatments. Those treatments involved surgery to remove the prostate -- involved radiation to destroy cells in the prostate. Those treatments can have side effects such as erectile dysfunction and even incontinence that affect a man’s quality of life. Although the treatments were effective for treating and curing the prostate cancer, it left men with many side effects that were unfavorable.
These days, given our new understanding of the slow-growing nature of the disease, many urologists will approach treating prostate cancer by doing something called active surveillance, which means repeating the PSA blood tests, possibly repeating prostate biopsies over the course of one to two years, and also using these sophisticated blood tests that I mentioned in addition to something we call Multi-Parametric MRI, which is an imaging technique – essentially an MRI of the prostate – to get a higher resolution view of the gland and also tumors that may exist inside.
Basically, to sum up, there have been some developments in the field that – exactly, have led the US Preventative Service Task Force to readdress whether given the new climate and the new landscape for the tools that we have, if we can better approach screening in a more sophisticated way.
Dr. Smith: Right. This is interesting, though. In the context of – let’s say there was a high PSA, there is the diagnosis of prostate cancer. We recognize it’s slow growing, so there is this surveillance type approach in some of these cases, and that’s where this new guideline comes from. However, does that apply to men maybe who are at more high risk for aggressive cancers? Does it apply to men in all age groups to do this watch and wait approach?
Dr. Whalen: Exactly. There are certain characteristics of the cancer once it’s diagnosed on a biopsy that makes watching a better and more favorable decision. It’s on a patient by patient, person to person basis who should be best served with a program of active surveillance. That being said, back in the early 2000s, active surveillance was only recommended for about 10% of patients. These days, it’s recommended for – what’s been published in the medical literature – between 40 and 50% of patients who are initially diagnosed.
The next steps for surveillance, as I mentioned, rely on possibly repeating that biopsy. In the past, because of the trend toward treatment for most men, the US Preventative Service Task Force initially gave Grade D recommendation against prostate cancer screening because of the potential harms of diagnosing prostate cancer in terms of those side effects of erectile dysfunction, and incontinence. Also, a large randomized trial was done in this country called the PLCO – the Prostate, Lung, Colon, and Ovarian Cancer Study – was unable to demonstrate a survival advantage for men who had been screened for prostate cancer compared to those who are not. However, that study was met with several methodologic flaws that make the interpretation of the results relatively limited. Given the shortcomings of that study upon which the initial recommendations are based and the new climate with a higher reliance on active surveillance, there’s been an upgrade in the recommendation from the Task Force.
In terms of the type of men and the proportion of men that qualify for active surveillance in this day and age – the majority of prostate cancers, because of prostate cancer screening in this country, are diagnosed with a low stage – in low grade, probably about 75% of the time. Going back to your question about who would be a candidate for active surveillance, that probably applies to about 70 to 75% of men that are diagnosed in the current era.
Dr. Smith: Got you. And so when you look at the Task Force and their specific wording, they say that they are in favor of shared decision-making between patients and their providers. Can you maybe just expound on that a little bit, what they mean by shared decision-making?
Dr. Whalen: Sure, and I’ll go back, actually – I think another component of your prior question was not only active surveillance and who that applies to, but also the recommendations of the Task Force. The people that we’re talking about that this should be applied to is men at average risk for prostate cancer between the ages of 55 to 70. These guidelines often have very specific recommendations, and men outside of those recommendations may not exactly apply, and there may be some nuances that make screening more or less favorable for them. Because prostate cancer is potentially slow growing, men over the age of 70 are not recommended for routine screening given that even if prostate cancer was diagnosed, it likely would be a disease that a man would die with, rather than of. Especially in the setting of other medical problems, prostate cancer would not be the primary issue in that setting.
Additionally, there are two categories of men in particular that warrant more specific attention and are not addressed by the general Task Force guidelines. Those two groups are men with a family history of prostate cancer, and also African American men. As I mentioned, African-American men have a higher incidence of prostate cancer. There’s also reports in the medical literature that the disease occurs at an earlier age, at a higher stage, and more aggressive type of prostate cancer, and has been associated with a higher chance of actually dying from prostate cancer.
The other group, as I mentioned, is men with a family history – that is men who have a father, grandfather, uncle or even brother with prostate cancer. Those men are at particularly higher risk as well. The general recommendations don’t apply to those men in terms of the age at initiation of screening of 55. The general recommendation from the Task Force is now at 55 years old, for the average-risk man, to start prostate cancer screening with the blood test and the rectal examination. For those in those particular categories of family history and African American race, they don’t make specific recommendations. There are other societies that do recommend earlier screening – The American Cancer Society, for example, recommends screening for those high-risk groups – African American men and family history, as I mentioned – starting around age 40 or even 45.
Dr. Smith: Got you. In summary, Dr. Whalen, what would you like people to know about prostate cancer and the updated screening guideline?
Dr. Whalen: Personally, I agree with the upgrade. There has been an undeniable decline in the rate of death from prostate cancer since the PSA has been introduced. And although it’s not a perfect test, we can’t deny that fewer men have been dying of prostate cancer since it was introduced. Treatment techniques have evolved such that the risks of incontinence and erectile dysfunction are not of a primary concern after initial diagnosis of prostate cancer – meaning just because you’re diagnosed doesn’t mean you need to be treated. The first step, even if your clinician recommends to a patient that he undergoes a biopsy, the first step is diagnosis, and then we can use our more sophisticated tools to understand and direct men on the path toward the treatment that would be best for them, and that may consist of active surveillance.
The first step would be screening and then filtering the patients to the appropriate provider or urologist to be able to interpret the screening results, and then recommend a biopsy if necessary, and to then possibly enter into a path of active surveillance. The guidelines from the US Preventative Services Task Force have been upgraded from D, which is against screening, to C. This applies to men ages 55 to 69 years old who are at average risk of prostate cancer. This is a change that makes their guidelines and recommendations in line with other national societies, such as The American Cancer Society and The American Urologic Association, which do endorse prostate screening.
Dr. Smith: Dr. Whalen, it sounds like what we’re seeing here is that moving into this Grade C recommendation is a step in the right direction because we are seeing survivals in prostate cancer improve and even the side-effects and the harm from treatment getting better. This seems to be very encouraging.
Dr. Whalen, I want to thank you for coming on the show today. The Urology Department at the George Washington University Hospital offers free prostate cancer screening to all men age 40 to 70 regardless of health insurance status. This screening is located at 22nd and I Streets, one block from the Foggy Bottom Metro Stop. To make an appointment for this screening, please call 202-741-3106. You’re listening to GW Hospital Health Cast with the George Washington University Hospital. For more information, you can go to GWHospital.com, that’s GWHospital.com. Physicians are independent practitioners who are not employees or agents of George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Dr. Mike Smith. Thanks for listening.
What the New Prostate Screening Guidelines Mean for Men’s Health
Dr. Mike Smith (Host): Welcome to GW Hospital Health Cast. I’m Dr. Mike Smith. The US Preventative Service Task Force recently updated its position on prostate cancer screening to a Grade C recommendation in favor of what they called “shared decision making” between patients and their providers. My guest, Dr. Michael Whalen, will explain what this means for men. Dr. Michael Whalen is a Urologic Oncologist and a member of the medical staff at the George Washington University Hospital. Dr. Whalen, welcome to the show.
Dr. Michael Whalen (Guest): Thanks for having me.
Dr. Smith: Let’s first talk about prostate cancer and prostate cancer screening and at least how we used to do that in the past before this update. Why don’t you give us a nice summary?
Dr. Whalen: Sure. Prostate cancer screening consists of a couple of things. One is a blood test known as a PSA or prostate specific antigen, which is obtained at the doctor’s office as part of regular laboratory work. The blood test is used in combination with what we call a digital rectal exam or manual finger examination of the prostate through the rectum. Those two tests are taken together to assess a man’s risk of having prostate cancer. Prostate cancer is a very common disease. It’s found in about one in six or seven Caucasian men and about one in five African American men and is one of the most common cancers that affects men in this country.
The PSA blood test is interpreted by the Urologist to determine how likely a man is to have prostate cancer. There’s no real normal value, but the interpretation is made with the patient to guide them toward the next steps in the evaluation, which may consist of other blood testing or imaging techniques or even moving on to a prostate biopsy.
Dr. Smith: Got you. When you look at the current way of doing this, then – you have the physical exam, and then you have the PSA blood test – how good of a screen was this process, then, for diagnosing prostate cancer?
Dr. Whalen: That’s a great question. The PSA blood test – truth be told – was initially used to detect any recurrent cancer after men had been treated with surgery to remove the prostate. You may imagine if the prostate is removed from the body, then that blood test basically should be zero. It shouldn’t show any of this enzyme, which is the substrate that we’re looking for with the blood test. The test was appropriated to be used as a screening tool – and in that respect, it doesn’t perform so well. In fact, it detects a lot of false positives because it’s not a specific test. We say it’s sensitive because it picks up a lot of men, but it’s not specific, meaning it doesn’t hone in and target specifically men who have prostate cancer.
If the PSA is elevated, it could mean that there is a tumor in the prostate or prostate cancer, but it could also be elevated for a few other reasons. One can be inflammation or infection of the prostate. Two, even recent sexual activity within about 48 to 72 hours, and three, benign enlargement of the prostate, which is something that occurs as men age and is responsible for a lot of urinary symptoms that older men experience. One thing that I tell patients is that the PSA is sensitive, but not specific, and in fact, casts a wide net and catches some dolphins in with the tuna. We don’t want to catch the dolphins. We only want to catch the tuna.
Dr. Smith: Right, right.
Dr. Whalen: These days, there’s more specific blood tests that we can do to determine a man’s risk of having a potentially aggressive prostate cancer rather than just low-grade prostate cancer. One thing to keep in mind is that unlike some other cancers that affect the people in this country like pancreatic cancer or even lung cancer – which are very rapidly growing and can be fatal – prostate cancer is often a slow-growing disease and may even be able to be watched rather than treated. There’s a current movement toward less is more in understanding that not all men that are diagnosed with prostate cancer have to be treated. In addition, there are more sophisticated blood tests that can stratify men into risk categories that may need to be treated and may be able to be watched.
Dr. Smith: Okay, and so is this then what led – with the idea that the PSA itself is sensitive where it tells you there’s something going on, but not specific to cancer – is this why then the US Preventative Service Task Force wanted to look at this and maybe reevaluate the screening process for prostate cancer.
Dr. Whalen: Exactly. In the past, the pendulum swung to more aggressive treatments. Those treatments involved surgery to remove the prostate -- involved radiation to destroy cells in the prostate. Those treatments can have side effects such as erectile dysfunction and even incontinence that affect a man’s quality of life. Although the treatments were effective for treating and curing the prostate cancer, it left men with many side effects that were unfavorable.
These days, given our new understanding of the slow-growing nature of the disease, many urologists will approach treating prostate cancer by doing something called active surveillance, which means repeating the PSA blood tests, possibly repeating prostate biopsies over the course of one to two years, and also using these sophisticated blood tests that I mentioned in addition to something we call Multi-Parametric MRI, which is an imaging technique – essentially an MRI of the prostate – to get a higher resolution view of the gland and also tumors that may exist inside.
Basically, to sum up, there have been some developments in the field that – exactly, have led the US Preventative Service Task Force to readdress whether given the new climate and the new landscape for the tools that we have, if we can better approach screening in a more sophisticated way.
Dr. Smith: Right. This is interesting, though. In the context of – let’s say there was a high PSA, there is the diagnosis of prostate cancer. We recognize it’s slow growing, so there is this surveillance type approach in some of these cases, and that’s where this new guideline comes from. However, does that apply to men maybe who are at more high risk for aggressive cancers? Does it apply to men in all age groups to do this watch and wait approach?
Dr. Whalen: Exactly. There are certain characteristics of the cancer once it’s diagnosed on a biopsy that makes watching a better and more favorable decision. It’s on a patient by patient, person to person basis who should be best served with a program of active surveillance. That being said, back in the early 2000s, active surveillance was only recommended for about 10% of patients. These days, it’s recommended for – what’s been published in the medical literature – between 40 and 50% of patients who are initially diagnosed.
The next steps for surveillance, as I mentioned, rely on possibly repeating that biopsy. In the past, because of the trend toward treatment for most men, the US Preventative Service Task Force initially gave Grade D recommendation against prostate cancer screening because of the potential harms of diagnosing prostate cancer in terms of those side effects of erectile dysfunction, and incontinence. Also, a large randomized trial was done in this country called the PLCO – the Prostate, Lung, Colon, and Ovarian Cancer Study – was unable to demonstrate a survival advantage for men who had been screened for prostate cancer compared to those who are not. However, that study was met with several methodologic flaws that make the interpretation of the results relatively limited. Given the shortcomings of that study upon which the initial recommendations are based and the new climate with a higher reliance on active surveillance, there’s been an upgrade in the recommendation from the Task Force.
In terms of the type of men and the proportion of men that qualify for active surveillance in this day and age – the majority of prostate cancers, because of prostate cancer screening in this country, are diagnosed with a low stage – in low grade, probably about 75% of the time. Going back to your question about who would be a candidate for active surveillance, that probably applies to about 70 to 75% of men that are diagnosed in the current era.
Dr. Smith: Got you. And so when you look at the Task Force and their specific wording, they say that they are in favor of shared decision-making between patients and their providers. Can you maybe just expound on that a little bit, what they mean by shared decision-making?
Dr. Whalen: Sure, and I’ll go back, actually – I think another component of your prior question was not only active surveillance and who that applies to, but also the recommendations of the Task Force. The people that we’re talking about that this should be applied to is men at average risk for prostate cancer between the ages of 55 to 70. These guidelines often have very specific recommendations, and men outside of those recommendations may not exactly apply, and there may be some nuances that make screening more or less favorable for them. Because prostate cancer is potentially slow growing, men over the age of 70 are not recommended for routine screening given that even if prostate cancer was diagnosed, it likely would be a disease that a man would die with, rather than of. Especially in the setting of other medical problems, prostate cancer would not be the primary issue in that setting.
Additionally, there are two categories of men in particular that warrant more specific attention and are not addressed by the general Task Force guidelines. Those two groups are men with a family history of prostate cancer, and also African American men. As I mentioned, African-American men have a higher incidence of prostate cancer. There’s also reports in the medical literature that the disease occurs at an earlier age, at a higher stage, and more aggressive type of prostate cancer, and has been associated with a higher chance of actually dying from prostate cancer.
The other group, as I mentioned, is men with a family history – that is men who have a father, grandfather, uncle or even brother with prostate cancer. Those men are at particularly higher risk as well. The general recommendations don’t apply to those men in terms of the age at initiation of screening of 55. The general recommendation from the Task Force is now at 55 years old, for the average-risk man, to start prostate cancer screening with the blood test and the rectal examination. For those in those particular categories of family history and African American race, they don’t make specific recommendations. There are other societies that do recommend earlier screening – The American Cancer Society, for example, recommends screening for those high-risk groups – African American men and family history, as I mentioned – starting around age 40 or even 45.
Dr. Smith: Got you. In summary, Dr. Whalen, what would you like people to know about prostate cancer and the updated screening guideline?
Dr. Whalen: Personally, I agree with the upgrade. There has been an undeniable decline in the rate of death from prostate cancer since the PSA has been introduced. And although it’s not a perfect test, we can’t deny that fewer men have been dying of prostate cancer since it was introduced. Treatment techniques have evolved such that the risks of incontinence and erectile dysfunction are not of a primary concern after initial diagnosis of prostate cancer – meaning just because you’re diagnosed doesn’t mean you need to be treated. The first step, even if your clinician recommends to a patient that he undergoes a biopsy, the first step is diagnosis, and then we can use our more sophisticated tools to understand and direct men on the path toward the treatment that would be best for them, and that may consist of active surveillance.
The first step would be screening and then filtering the patients to the appropriate provider or urologist to be able to interpret the screening results, and then recommend a biopsy if necessary, and to then possibly enter into a path of active surveillance. The guidelines from the US Preventative Services Task Force have been upgraded from D, which is against screening, to C. This applies to men ages 55 to 69 years old who are at average risk of prostate cancer. This is a change that makes their guidelines and recommendations in line with other national societies, such as The American Cancer Society and The American Urologic Association, which do endorse prostate screening.
Dr. Smith: Dr. Whalen, it sounds like what we’re seeing here is that moving into this Grade C recommendation is a step in the right direction because we are seeing survivals in prostate cancer improve and even the side-effects and the harm from treatment getting better. This seems to be very encouraging.
Dr. Whalen, I want to thank you for coming on the show today. The Urology Department at the George Washington University Hospital offers free prostate cancer screening to all men age 40 to 70 regardless of health insurance status. This screening is located at 22nd and I Streets, one block from the Foggy Bottom Metro Stop. To make an appointment for this screening, please call 202-741-3106. You’re listening to GW Hospital Health Cast with the George Washington University Hospital. For more information, you can go to GWHospital.com, that’s GWHospital.com. Physicians are independent practitioners who are not employees or agents of George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Dr. Mike Smith. Thanks for listening.