Prostate cancer: when to get tested? – 01/11/2023 – Balance and Health

With Inca (National Cancer Institute) estimating almost 72,000 new cases of prostate cancer each year for the 2023-2025 period, it is expected that expert guidance will be the same as for other types of tumors: the earlier detection, the greater the chances of treatment and, possibly, cure.

However, both in Brazil and in other countries around the world, such as the United States, there is no official indication for so-called prostate tumor screening in men.

The Primary Health Care Secretariat of the Ministry of Health published a technical note on the 25th in which it recommends not screening the population for prostate cancer. It is important to highlight that this recommendation is not new, and the Ministry of Health has adopted this practice since 2015.

Likewise, the American CDC (Center for Disease Control and Prevention) does not recommend screening men in the country for prostate cancer using the PSA test.

The WHO (World Health Organization), on the other hand, adopts a position in which it recognizes that the barriers to implementing an effective screening program are the high frequency of indolent tumors (which do not progress clinically) as age increases and a high morbidity (damage to health, which can be disabling) related to the procedures used to treat prostate cancer.

The Council of the European Union published, in December 2022, a document in which it states that countries must evaluate the feasibility and effectiveness of population screening for prostate cancer and the implementation of organized programs for early detection.

Prostate cancer occurs due to an abnormal multiplication of prostate cells, forming what doctors call prostatic hyperplasia. It can appear in four stages or phases, from least aggressive to most aggressive.

In general, in the early stages, prostate cancer is asymptomatic and does not change the patient’s life. In the advanced stage, it can cause pain, the urge to urinate all the time, including at night (called nocturia), blood when urinating and erectile dysfunction.

The risk factors associated with prostate cancer are, firstly, age, followed by family history, smoking, overweight and obesity.

In addition to the digital rectal exam, prostate cancer is detected by changes in the so-called free PSA (prostate-specific antigen).

According to the Ministry of Health, although early diagnosis is important to detect cancer in its early stages, recent systematic reviews (studies that synthesize the knowledge produced so far and present new data or interpretation of a subject) have identified that screening significantly increases the number of new cases, but without a significant reduction in mortality.

They cite a 2019 study conducted in Europe that followed thousands of patients for 16 years and found no significant reduction in prostate cancer-specific mortality associated with population screening.

In other words, what many doctors call “overdiagnosis” is carried out: the detection of tumors that do not necessarily have an impact on the patient’s life. “Through the attempt to make an early diagnosis, with screening, there is a high number of new cancer diagnoses that do not generate significant problems or health problems throughout the patient’s life”, says the coordinator of Men’s Health Care from the Ministry of Health, Celmário Brandão.

According to him, the ministry is based on evidence that indicates that there is no benefit from the point of view of reducing mortality. “There is a strong association with problems related to access to services, access to exams and then the so-called ‘overtreatment’, which is the treatment of people without need because they die of other causes, not prostate cancer”, he explains.

The SBU (Brazilian Society of Urology), on the other hand, maintains the recommendation of population screening in men aged 50 or over or, in the case of a family history, aged 45 or over, explains the professor of Uro-oncology at Unicamp and manager doctor at AC Camargo, Walter Henriques da Costa. “We understand that there are important population differences between Brazil and these countries, for example, which require a more differentiated look at the Brazilian situation, where there is a high incidence of cases diagnosed in advanced stages of the disease.”

According to Costa, the data used by the Ministry of Health is considered the most rigorous in terms of current scientific evidence, but there are also consistent studies carried out in countries like Sweden that found a benefit from screening in that population. “In the case of Brazil, the inequality in access for exclusive SUS patients in relation to private healthcare is also another barrier, and around 35% of cases are already detected in the advanced stage”, he states.

Brandão reinforces that the ministry does not recommend screening because it understands that actions to promote and prevent men’s health are more effective when implemented throughout the year, and not just in Blue November. “States and municipalities should take advantage of this moment to raise awareness about comprehensive care for men’s health, and not just carry out as many tests to detect prostate cancer as possible per month,” he says.

Similarly, Costa believes that individualized care is essential. “We believe in searching for the best diagnosis for each patient. There is no point diagnosing prostate cancer in an elderly patient, with several comorbidities, who does not have a high life expectancy and will probably face anxiety generated by the discovery of the tumor. Healthy men, on the other hand, over 70, 80 years old, and who will live longer, it is possible that the discovery could help in so-called active surveillance”, he says.