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Prostate testing debate

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Prostate data renew debate
By Tim Friend, USA TODAY

Controversy over prostate cancer screening surfaces again Wednesday with a study that suggests up to half of men given the prostate specific antigen (PSA) test would have been better off without it.

The study in the Journal of the National Cancer Institute concludes that testing less often than once a year can spare many men the ordeal of being diagnosed with a tumor so slow-growing that it wouldn't shorten their life even without treatment.

The findings are based on computer modeling of preliminary data from more than 40,000 European men in the study led by Gerrit Draisma, University Medical Center Rotterdam, Netherlands.

Half of men age 50 and older get the PSA test annually. The tests are controversial because not all prostate cancers are lethal.

Depending on age, 20% to 50% of men who die from causes other than cancer are found through autopsies to have had slow-growing prostate tumors that would have been unlikely to cause illness until very old age if at all.

PSA testing cannot distinguish between a slow-growing and an aggressive tumor, although a very high reading can indicate aggressiveness. Once a man is found with any elevated level of PSA, doctors and patients find it difficult to ignore. Treatment with surgery or radiation usually is recommended. Surgery has a high risk of impotence and urinary incontinence. Radiation therapy has a high risk of bowel problems and impotence.

The younger a man is at diagnosis, the more likely his doctor will be to recommend treatment. However, these men are most likely to have slow-growing tumors.

The issue is complicated by the fact that an unknown subset of these younger men will have the most aggressive cancers. And so the debate continues.

Michael Manyak, chairman of urology at George Washington University Medical Center, Washington, D.C., says urologists are compelled to screen and treat younger patients.

"We still are unable at this stage to determine accurately enough by means of a history and physical which patients will have aggressive tumors. So we are forced to screen a larger population knowing that some people will be over-diagnosed," Manyak says. "Until we make that determination, we are obligated to treat younger men more aggressively."

Says Timothy R. Church, of the University of Minnesota, who wrote an accompanying editorial: "This is very valuable and interesting work, but for us to make decisions about screening on a computer simulation we need to make sure their model is valid. If one looks carefully, there are a number of questions to be raised. We can't take it at face value."

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