Over a decade ago, I did some research in the area of PSA testing and prostate cancer, so this field is a personal interest of mine. My impression from reading the NY Times article, The Great Prostate Mistake, by the pathologist who discovered the test, is that questions being asked in the nineties are being answered more and more in the negative.
In the large study I worked on, we found that lowering the threshold level of PSA deemed worrisome in younger men resulted in more positive biopsies, including biopsies with apparently significant higher grade/aggressive cancer, but whether or not treating those cancer had overall beneficial results wasn’t known or determined. This illustrates a common dilemma in medical science – what happens when detection methods advance before sufficient evidence exists as to the risks and rewards of potential treatment options? The goal shouldn’t be to simply find cancer, but to promote a healthful life. The words "do no harm" are particularly meaningful. With that, let’s move on to the thoughts of John Wrenn MD, a practicing urologist who sent me the NY Times article along with his thoughts on the subject. – Ilene
My Take On The Prostate
Courtesy of John Wrenn, MD
As a urologist, I make a lot of my living off of prostate health and certainly have concerns about over testing, over diagnosis and over treatment. The biggest question remains, in my opinion, who to treat more than anything else. I think PSA screening is probably on par with Mammograms and cholesterol testing as far as questionable value is concerned. Colonoscopy doesn’t seem as dubious largely because colon cancer tends to have fewer gray areas as to who needs treatment, and while invasive, screening for colon cancer doesn’t lead a significant portion of patients with positive findings to treatments that only make a difference in cancer specific survival for a few, while causing life altering functional changes in many.
I am still not sure that America is ready to return to a medical system where treatment is only given when the disease becomes symptomatic or grossly detectible, although the outcomes would probably be only marginally different for many diseases and the savings to the system would be massive. I think the challenge for urology as a profession is to work harder to determine who needs aggressive therapy and who needs observation. The sentiment toward screening may fade, but entrenched habits in medicine often take years to be overcome, just as new more effective therapies often take years to gain acceptance.
I often will have a patient come in who has had an elevated PSA and was found to have cancer, and he wonders why it wasn’t detected sooner and why the primary care physician didn’t get the PSA measured in prior years. The PSA is currently imprinted on the psyche of the American male. If you don’t measure it, and the patient develops a cancer that is no longer locally confined, you can stand back and wait for the lawyers to call. That imprint will take time to change. A prostate cancer death tends to be an unpleasant death and there is merit in trying to reduce that risk particularly in younger men. The pendulum has swung too far in one direction, but it doesn’t need to go all the way back to the other side.
I think an early baseline PSA at about 40 years of age has value. It is important to know where you start so you can judge the future values on relative terms. I would also recommend that if the PSA is only mildly elevated that there maybe value in following it for a few months because if it is stable, even if there is cancer, the risk of progression is low. Another situation that I see is the patient whose PSA has jumped dramatically over a year’s time. I always repeat the PSA because frequently it will come back with a different, often lower, value on the repeat test. Lab error is always a possibility and it is unusual for a PSA to jump several points in a year due to most cancers. Sadly, the cancers that cause a jump of several points in a year tend to be the least responsive to therapy anyway.
If we spent a small fraction of the money we spend on screening and treatment for indolent disease on diet modification, exercise programs, alcohol and drug therapy, smoking cessation and mental health, we would probably get a lot more bang for our buck, but I don’t see that happening anytime soon. Too many profit centers rely on the current trends in medicine to go down without a fight.
John
Disclaimer: This is a general discussion and not meant as medical advice.
The Great Prostate Mistake
By Richard J. Ablin
http://www.nytimes.com/2010/03/10/opinion/10Ablin.html
EACH year some 30 million American men undergo testing for prostate-specific antigen, an enzyme made by the prostate. Approved by the Food and Drug Administration in 1994, the P.S.A. test is the most commonly used tool for detecting prostate cancer.
The test’s popularity has led to a hugely expensive public health disaster. It’s an issue I am painfully familiar with — I discovered P.S.A. in 1970. As Congress searches for ways to cut costs in our health care system, a significant savings could come from changing the way the antigen is used to screen for prostate cancer.
Americans spend an enormous amount testing for prostate cancer. The annual bill for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.
Prostate cancer may get a lot of press, but consider the numbers: American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That’s because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.
Richard J. Ablin is a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research.
