Has it really been a year since the last National Prostate Cancer Awareness Month? It seems like only yesterday that I posted a blog here confessing that I had been avoiding my annual physical exam appointment in dread of the obligatory digital rectal exam (DRE).
To explain my dread, I quoted a Johns Hopkins Medicine whitepaper on prostate disorders that said the DRE “involves the insertion of a gloved, lubricated finger into the rectum, is mildly uncomfortable but extremely important." I also explained that my internist is a friend named Alan, and that the thought of his inserting a “gloved lubricated finger” into my rectum made my skin crawl.
Nevertheless, I promised to make an appointment, and so I did, although I continued to stall for a few more months. Eventually, I decided it was better to get it over with than to keep seeing annoying and increasingly strident reminder notes from my wife attached to my computer screen, the bathroom mirror, refrigerator, and microwave doors, or anyplace else she could think of to badger me about it. The appointment was in May.
Alan looked good considering I hadn’t seen him in almost three years. We had a lot of catching up to do and I kept the conversation going as long as I could before he gave the inevitable order to bend over.
Consummate professional that he is, Alan pretended not to notice my discomfort and quickly picked up the conversation where we had left off once he had done the deed and reported that my prostate “felt normal.” As always, we talked about weighty matters such as the Israeli-Palestinian conflict, the current political situation, and the healthcare system in the United States. But soon, he returned to discussion of my prostate... and, somewhat surprisingly, to his.
We are both in our 60s and neither of us has ever had a prostate specific antigen (PSA) test. We have both followed the ongoing debate as to the risk/benefit and usefulness of PSA screening for prostate cancer. Alan said he used to routinely advise patients to have it. Now he is ambivalent.
Recently, when he had his own annual physical exam, he declined it. “How can I, in good conscience, recommend to my patients that they have it done if I am not prepared to do it myself?”
I decided against it, too, at least for now. We both hope that new biomarkers currently under investigation will soon make the PSA test obsolete for men our age. (And maybe they’ll find a more pleasant alternative to the DRE while they’re at it.)
Last month, at the Prostate Cancer World Congress in Melbourne, Australia, an international panel of experts issued a five-point “consensus statement” in an attempt to bring some much-needed clarity to the confusion that exists with existing guidelines “and to present reasonable and rational guidance for the early detection of prostate cancer today.”
The five points are as follows:
- For men aged 50–69, level 1- evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer.
- Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.
- PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.
- Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.
- Older men in good health with over 10 year life expectancy should not be denied PSA testing on the basis of their age.
Each point is followed by a referenced explanation. You can decide for yourself if you think the statement brings clarity to the confusion over existing guidelines. But I’m still as confused as ever.