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Digital Subscriptions > Skeptical Inquirer > January/February 2019 > Screening for Prostate and Breast Cancer: It’s More Complex Than You May Think

Screening for Prostate and Breast Cancer: It’s More Complex Than You May Think

Cancer screening searches for cancer before its symptoms appear. Messages encouraging screening for prostate and breast cancer are not only filled with misleading statistics, they also do not discuss the most significant harm of screening: being diagnosed and treated needlessly.

“Pink October” and “Blue November” are campaigns to promote awareness for breast and prostate cancer, respectively. In Brazil, as well as in other countries, the population is encouraged to do tests such as the prostate-specific antigen (PSA) for prostate cancer and mammography for breast cancer.

The main idea is screening: to perform tests in healthy persons to detect and to treat diseases before their symptoms appear to increase the chances of cure and even to offer a less aggressive treatment. A good example of cancer screening is for cervical cancer, where incidence of the advanced cases decreased after the Papanicolaou test was introduced (Adegoke et al. 2012). However, studies that assess the efficacy of screening for prostate or breast cancer show that in reality things are more complicated than usually advertised by those campaigns.

In May 2018, the U.S. Preventive Services Task Force (USPSTF) reviewed studies of PSA screening for prostate cancer (Fenton et al. 2018). Only two randomized controlled trials were of sufficient quality to assess impact on mortality. One, called the PLCO,1 did not show differences in mortality. The second trial, called ERSPC,2 showed that screening reduced prostate cancer mortality in men aged fifty-five to sixty-nine. Even in that case, it’s far from simple. In order to avoid one prostate cancer death and three cases of meta-static prostate cancer, 1,000 men aged fifty-five to sixty-nine have to be screened every four years during thirteen years. Of those, twenty-seven men received treatment—prostate surgery and/or radiation therapy. More important, the majority of those who were treated, twenty-four patients, received aggressive treatment with no benefits, only the harms caused by the treatment itself. Regardless of screening, five men died from prostate cancer. See Table 1 for complete estimates.

A careful analysis of cancer screening must consider harms of treatment. The USPSTF review found that of those who undergo complete prostate surgery, one in five men develop urinary incontinence and two in three experience impotence. More than half of those who receive radiation therapy develop impotence and one in six men develop bowel symptoms, including bowel urgency and fecal incontinence (Fenton et al. 2018).

The overall view that prostate cancer screening might cause more harm than good is far from new. A 2013 Cochrane meta-analysis (Ilic et al. 2013) of five studies showed no reduction in mortality, and in 2012 USPSTF recommended against screening regardless of age. At present, the USPSTF concludes the benefits and harms of screening for men aged fifty-five to sixty-nine are balanced, recommending an individualized decision after a careful consideration of potential benefits and harms. For men aged seventy and older, the USPSTF recommends against screening. See Figure 1 for USPSTF decision aid.

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