If there is one thing that the COVID pandemic taught us, it was the lack of flexibility, nimbleness and the frequent inaccuracy or out of datedness of superimposed guidelines. I must confess that as a practicing internist for many years, I have never strictly adhered to guidelines and simply used them to guide me. Medicine is and always has been an art to be practiced on an individual basis.
One of the guidelines that has bothered me the most is the U.S. Preventive Services Task Force Guideline – in use since 2012 — not to recommend routine Prostate Specific Antigen use in prostate cancer screening. And even the American Urological Association doesn’t recommend routine screening over the age of 70. Studies have shown that use of the PSA has fallen off likely in men over the age of 40 as a result of the USPSTF recommendation. This is particularly disturbing considering that there are over 300,000 new cases of prostate cancer in the U.S. diagnosed every year, with over 35,000 deaths, many of which may be preventable with earlier diagnosis.
So it is disturbingly possible that former President Biden’s spokesperson is telling the truth when he says that he wasn’t screened for prostate cancer in over a decade prior to his current diagnosis of aggressive metastatic disease. Perhaps he and his doctors were just rigidly following an outdated and ill-conceived guideline. But this revelation, if true, is just as disturbing as if the Biden White House were hiding a timelier earlier diagnosis from the American public, just as they have apparently hidden other health realities regarding the former president.
Delay and guessing in the dark is simply not how I, and many other internists and urologists, practice medicine. The PSA itself tells us when it trends upward, often when it increases over 4, that there is something going on in the prostate. The rise may or may not be due to prostate cancer. When combined with a “free PSA,” if low, the likelihood of prostate cancer increases. We are also on the verge of genetic testing and liquid biopsies (blood tests) which will increase the accuracy of prostate cancer screening and we already have useful biomarker screening tests for prostate cancer in the urine.
Luckily, despite the fact that current screening guidelines are not up-to-date or useful, I can still order a PSA and have Medicare cover it for any age if I say the test is medically necessary.
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I need to know that information, combined with a digital rectal exam looking for nodules, to know what to do next regardless of my patient’s age. If either test is abnormal, I can then choose to proceed to an MRI of the prostate, which has become more accurate at looking for prostate cancer as the test has evolved and advanced. An MRI result can direct a urologist as to whether a biopsy is necessary and where in the prostate to direct this biopsy.
If a patient has prostate cancer, there are many treatment options available, depending on the stage and aggressivity. These treatments have also advanced over the years and are better tolerated with fewer side effects, which means they may be tolerated by men of older ages and in poorer health. If a cure is possible, then either robotic radical prostatectomy or various forms of radiation treatments are considered. And if the prostate cancer is metastatic, as in President Joe Biden’s case, hormone therapy to target testosterone (which may be causing the tumor to grow), may be used or combined with other treatments, including targeted therapies, immunotherapy, or chemotherapy. There are even studies which show that it may improve outcome to still remove the prostate even in some advanced cases.
Many critics are saying that a president of the United States should have the most aggressive prostate cancer screening regardless simply because he is president. But I am saying that all men over the age of 45 should have this screening. Period. Regardless of age.
Medical knowledge is power and what I do with the information I acquire to help my patient is the art of medicine. Not knowing is never the correct answer.
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