PROSTATE CANCER SCREENING, AN ONGOING CONTROVERSY.

Prostate cancer screening always raises a lot of controversy on account various reasons; most notable among these is the nature of the physical exam recommended for screening, digital rectal exam (DRE). On a discussion on digital rectal exam one Ghanaian friend of mine said categorically ” there would be no gay probing of my nether parts”. That reminded me of my first and only death threat from a patient, which I count as fortunate since some colleagues do report worse. As a very eager young physician working in a safety net clinic in Baltimore Maryland I realized the need for aggressive screening for all my patients since I was usually the only physician that they would most probably be seeing for several years especially if they failed to follow up. I therefore always tried to do as much as I can in a single visit. This is a habit that I picked up from my residency at Chicago’s John Stroger Hospital of Cook County’s  Fantus Clinic which happened to serve such a population. I performed a digital rectal exam on the recent prison inmate on his first visit to the clinic and after the procedure though he was not violent he went back to his transitional shared housing and informed his colleagues that I stuck my finger up his rectum and he was going to kill me. Word eventually got to me of this threat through our CEO and we filed a police report and banned the patient from our clinic. So yes I nearly lost my life over a digital rectal exam or (DRE) for short.

Thus for someone who received death threats for performing DRE one would expect me to take prostate cancer screening very seriously.  Over the past two decades though the screening for prostate cancer has moved from a fairly stable strong recommendation in to the realm of individualized risk determination and shared decision making. Whilst this situation is very logical and is based on current research data this can be very complicated to follow and more often than not most patients end up being managed based on the views and biases of their physicians.  In the US recommendations of the United States Preventive services Taskforce (USPSTF) recommends screening from age 55-70 years for average risk individuals and earlier screening for African American men without giving any specific age cut off. In the United States studies suggest that African American men are twice as likely compared to whites to be diagnosed with prostate cancer and tend to have more aggressive tumors. This may therefore suggest earlier screening for African American men but the guideline fails to give a specific age, cut-point.

In Ghana an institution based retrospective study of diagnosed prostate cancer involving 512 cases conducted by researchers at the Kwame Nkrumah University of Science and Technology suggests that 95% of diagnosed Prostate Cancer was in men older than 50 yrs.  One weakness of this study was the lack of data on stages of diagnosed cases. Another population based study funded by the NIH shown a that using a PSA > 2.5 ng/ml yielded a 7% screening positive rate whilst using a > 4 ng/ml yielded 6.3% positive. This appears much higher than similar aged US cohorts however when one considers that US populations tend to be highly screened and as such lower rates would be expected. A Missouri cohort of black males also yielded a positivity rate of 5.4%.  While it is definitely clear that prostate cancer risk is higher in men of African descent both on the continent of Africa and in the diaspora there is not enough research data to make any strong recommendations on different screening modalities according to USPSTF. Also men with history of prostate cancer in a close relative before age 55 years are also considered high risk for prostate cancer.

PROSTATE CANCER STAGING
Different stages on prostate cancer

There is clearly a need for more research on prostate cancer screening among men of African descent to help fill the knowledge gaps on the benefits of screening. In the interim it is definitely prudent that appropriate individuals specifically men of African descent and those with a positive family history need to have discussions on the potential benefits and harms of screening. Any screening programs in these populations should be structured as pilot projects to obtain more data on the risk vrs benefits of screening.

Talk-to-Doc
Shared decision making is a must for discussion on prostate cancer screening

At this time based on current research conversations about screening for prostate cancer have to be very nuanced to ensure we are getting the most out of our doctors visits. In Ghana based on the limited data available the most benefits to screening may be for men older than 50 years of age.  This age cut off could be adjusted for individuals with family history especially if the family member is diagnosed before age 55 years. This is based on studies that suggest that about individuals with a father or grandfather with history  of prostate cancer cases have a 30% increased risk of prostate cancer compared to those without family history.

So my brothers please consider prostate cancer screening based on your age, race and family history. Just know that when it comes to DRE most providers hate this screening test as much as you do so no doctor would be forcing you to get this test done if you do not need to get that done. Unfortunately though account of the current controversy on the harms as compared to the benefits of prostate cancer screening most patients need to get well educated on the harms and benefits of screening to assist in making better decisions on their health.

By Dr. Leonard Sowah, an internal medicine physician in Baltimore, Maryland 

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