For men in Canada prostate cancer can be a worry. There are often stories in the news regarding prostate cancer, the pros and cons of PSA (Prostate Specific Antigen) screening for prostate cancer, and fundraisers for prostate cancer awareness.
The PSA is a blood test, albeit an imperfect test, that becomes elevated in most cases of prostate cancer. It can become elevated for other reasons, causing confusion. A digital rectal exam (DRE) is part of a physical exam when a health provider inserts a finger into the rectum to feel a portion of the prostate. This too is an imperfect test. Taken together though, these tests become more useful. Opinions differ however on the usefulness of PSA and DRE for screening of prostate cancer.
In 2014,The Canadian Task Force on Preventive Health Care (CTFPHC) released guidelines recommending NOT screening men in Canada for prostate cancer with PSA, due to perceived uncertain benefits, and possible harm. This proved to be very controversial. A concern with screening for prostate cancer has been that, possibly, too many men are diagnosed, then treated, when many of these men don’t benefit from treatment, and suffer side effects of treatment.
The Canadian Urological Association (CUA)and Prostate Cancer Canada have publicly disagreed with the position of the Task Force (CTFPHC).The CUA is an organization of Canadian Urologists and other providers who deal with Prostate Cancer in Canada. Prostate Cancer Canada is a national foundation which advocates for support, awareness, and further research for Prostate Cancer. The goals of Prostate Cancer Canada are to fund research into better diagnosis of prostate cancer, and better treatments for prostate cancer, and to provide support for families in Canada affected by prostate cancer. The Canadian Cancer Society also provides information and advice regarding prostate cancer and prostate cancer screening for men in Canada.
Prostate Cancer Canada and the CUA believe in ‘Smart Screening’, which takes into account each individual man’s personal risk, and with this approach men are encouraged to be tested with PSA to establish a baseline number. Then the frequency of follow up would be based on that person’s individual risk profile. If there are changes in the level of PSA over time, the man and his doctor decide together how to move forward based on his profile. A Family history of prostate cancer is one risk factor. Canadian men of African descent may also be at higher risk, and of more aggressive forms of prostate cancer.
If there is suspicion of prostate cancer, prostate biopsy is typically suggested. If prostate cancer is diagnosed, this does not necessarily mean treatment is needed. If the biopsy shows an aggressive or advanced form of cancer, then treatment with radiation or surgery may be recommended. But if the cancer is deemed to be slow growing, an approach called Active Surveillance may be suggested. With this approach, the PSA level and DRE are checked over time, and biopsies may be repeated at certain intervals. Many men will never require treatment.
In the view of many, the knowledge that one may have prostate cancer is of benefit to take control of the illness. Though it is likely that in past years too many men have been treated, the approach to prostate cancer diagnosis and management has become much more nuanced. Proponents of PSA testing feel that early detection saves lives. And since prostate cancer can have little or no symptoms in the early stages, proponents feel that without PSA testing, men would be diagnosed at a much later stage, and the death rate from the disease will rise. A man in Canada has a 1 in 7 chance of being diagnosed with prostate cancer, and a 1 in 27 chance of dying from prostate cancer.
The CUA guidelines from 2011 for PSA screening suggest offering men in Canada prostate cancer screening with PSA at age 50, and at age 40 if there is a family history or if the man is of African descent. There are also proponents of screening men in their 40’s to establish future risk of prostate cancer based on PSA level. Intervals of screening can be annually, or at an interval deemed suitable by the provider and patient, based on the PSA level, the rate of increase of PSA level, and risk factors for prostate cancer.
PSA screening for prostate cancer in a man without risk factors remains an uninsured service in Ontario and is therefore not covered by the provincial health plan (OHIP) to determine if prostate cancer screening with PSA is right for you, consider your risk factors, your personality, and your tolerance for uncertainty, and have the discussion with your health provider.
At Ontario Men’s Health clinic in Toronto, we work with men to determine what the best approach to screening for prostate cancer is for their personal situation, and can offer both PSA and DRE testing. Any man in Canada can also ask his family physician for advice about these tests as well.