ETHICS OF PROSTATE SCREENING Prostate cancer Usually asymptomatic May be picked up in routine rectal examination Late stages may

may present with bone pain in pelvic region or difficulty passing urine, after metastasis of the cancer
http://www.webmd.com/prostate-cancer/guide/understanding-prostate-cancer-symptoms

Prostate screening PSA test o Test for levels of prostate specific antigen in the blood o Only indicative, not diagnostic o Elevated PSA can also be caused by prostate enlargement, prostatitis, urinary infection o Approximately 2/3 of men with elevated PSA do not have prostate cancer Prostate biopsy o Diagnostic of prostate cancer o A sample of the prostate examined under the microscope will confirm diagnosis for prostate cancer o Generally safe o Minor risks (<1%) include pain, bleeding, hematuria, hematospermia and urinary tract infections o Approximately 2/3 of men who undergo prostate biopsy do not have prostate cancer
https://www.singhealth.com.sg/DoctorsAndHealthcareProfessionals/MedicalNews/2012/Pages/Prostate-Cancer-Screen-Not-2.aspx

Issue 1: PSA screening may not be effective enough to prevent deaths from prostate cancer
PSA screening increases mortality benefit o Study by European Randomized Study of Screening for Prostate Cancer (ERSPC) o Study concludes PSA screening decreases the chances of a man dying from prostate cancer by 21% o Main criticism include only Sweden and Netherlands reporting statistically significant reductions in prostate cancer mortality and a lack of explanation for why this is so

http://www.erspc-media.org/ http://www.uroweb.org/news/?act=showfull&aid=654

PSA screening has no mortality benefit o Another study by US preventative services task force found no significant benefit of PSA screening o USPSTF recommends against PSA-based screening for prostate cancer in healthy men o Main criticism of the study is the high rates of men in control group getting prostate screening

http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm#respons e http://www.uroweb.org/news/?act=showfull&aid=654

Issue 2: Overdiagnosis and overtreatment

o PSA results only have mediocre accuracy Approximately 2/3 of men with elevated PSA do not have prostate cancer o Study by USPSTF finds our that over 10 years, 15% to 20% of men will have a PSA results that triggers a biopsy, which carries risks o Current screening cannot determine accurately if a cancer will become dangerous, as a result, men may subject themselves to unnecessary treatment that can result in impotence and incontinence
http://healthland.time.com/2012/01/06/when-cancer-screening-does-more-harm-than-good/ http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm#respons e

Official guidelines in Singapore on prostate screening

High risk men should be screened annually Healthy men younger than 50 should not be screened routinely Men with life expectancy of less than 10 to 15 years should be informed that screening and treatment is unlikely to be beneficial

Ministry of Health (MOH) Singapore Clinical Practice Guidelines on Cancer Screening 1/2010 suggest the following groups (after having counselled about the risks and benefits of prostate cancer screening) could consider getting screened: Men who are between 50 to 75 years of age with an estimated life expectancy of more than 10 years. High-risk men African American men, men with a strong history of prostate cancer (one or more firstdegree relatives diagnosed before age 65 years) may be offered screening at an earlier age. Routine screening of men younger than 50 years of age should not be offered. Men with a life expectancy of less than 10 to 15 years should be informed that testing and 12 treatment is unlikely to be beneficial.

The PSA screening frequency as recommended by the above guidelines recommends it should be repeated annually. However the screening may be performed every two years in low risk men with a baseline PSA of less than 1.0ng/ml (recommended best practice by the guideline development group). https://www.singhealth.com.sg/DoctorsAndHealthcareProfessionals/MedicalNews/2012/Pages/Prostate-Cancer-Screen-Not-2.aspx