Finding cancer without screening

Dear Dr. Roach: Every year, I used to get a physical, which included a prostate exam as well as blood tests with PSA. When my doctor retired, I had a hard time finding a new one I liked. It has been three or four years since my prostate was checked, but my new doctor doesn’t do the prostate exams (I am 63). He says that recent studies do not recommend them. How do you find out if you have prostate cancer if you don’t look for it? I don’t really want to wait until I am showing symptoms, and there is no history in my direct family. — T.D.

Prostate cancer isn’t really one disease. It can be very aggressive, but it also can be very indolent, hardly growing at all. Yearly prostate cancer screening with PSA is more likely to find the slower-growing cancers. The goal of screening is to find aggressive cancers, the fast-growing ones that can go from undetectable to too-late-to-do-anything-about in a very short time.

But a downside is that screening may lead to unnecessary treatment of the more-indolent cancers, most of which can be carefully monitored and will not need surgery or radiation.

If a man elects to undergo prostate cancer screening, he should understand the benefits (finding prostate cancer early enough) and the risks (treatment for prostate cancer causes complications frequently). Not treating low-risk prostate cancer reduces risks.

Low-risk prostate cancer is defined by a PSA below 10, a very small or non-detectable tumor by palpation or imaging and a low Gleason score, which is based on how the tissue looks to the pathologist. Six or less is low risk. Most men in this situation do not need immediate treatment. Some men have difficulty NOT treating cancer, but treatment does not appear to improve the already good prognosis. Choosing not to treat is hard for some men.