Patrick J. Skerrett

Panel says “no” to routine prostate cancer testing

A simple blood test to check seemingly healthy men for hidden prostate cancer does more harm than good and shouldn’t be part of routine medical care. That’s the long-awaited final recommendation from the United States Preventive Services Task Force (USPSTF), published today in Annals of Internal Medicine.

About half of men over age 40 get this test as part of a regular checkup. It measures the amount of a protein called prostate-specific antigen, secreted by the walnut-sized prostate. An above-normal PSA level can signal hidden prostate cancer. But it can also be a sign of prostate infection, an enlarged prostate, and other problems. Hunting for hidden disease in the absence of any outward signs or symptoms is called screening.

The task force’s evidence-based rationale for saying “no” to routine prostate cancer screening using the PSA test goes like this. For every 1,000 men, routine PSA testing would:

  • prevent 0 to 1 deaths from prostate cancer.
  • identify 110 cases of prostate cancer (most of them unlikely to ever affect health or longevity)
  • cause serious cardiovascular events (heart attack, stroke, deep-vein thrombosis, or pulmonary embolism) in 3 men due to some of the treatments used for prostate cancer
  • cause treatment-related erectile dysfunction in 200 to 300 men
  • cause treatment-related urinary incontinence in 200 to 300 men

Most men and their doctors would agree that the harsh side effects of treating a life-threatening problem, like lung cancer or pancreatic cancer, are worth tolerating. But many men who are treated for prostate cancer picked up by PSA screening have tumors they never would have noticed  otherwise. These men would suffer more from prostate cancer treatment than they would from the cancer itself.

“What most people don’t realize is that most prostate cancers never spread and cause suffering. Under the microscope, they look like a disease. But they don’t act like a disease. With those cancers, the treatment always is worse than the disease. What we desperately need is a test that distinguishes between the occasional prostate cancers that spread and cause suffering, even death, and the much more frequent prostate cancers that will never cause suffering. The PSA is not that test,” says Dr. Anthony Komaroff, professor of medicine at Harvard Medical School and editor in chief of the Harvard Health Letter.

Controversial recommendation

Although prostate cancer is usually slow growing, it isn’t always. An estimated 28,000 men will die of prostate cancer this year. It’s the second leading cause of cancer deaths in the United States, behind lung cancer, which will kill nearly 90,000 men this year.

Advocates of routine PSA testing say that the test saves lives. In a commentary that accompanied the USPSTF’s recommendation, nine prostate cancer specialists argue that detecting prostate cancer in younger men (meaning those in their mid-40s or 50s), who can look forward to another 30 years of life, is important. As Northwestern University’s Dr. William Catalona, one of the commentary authors, told NPR, “If all PSA screening were to stop, there would be thousands of men who would unnecessarily suffer and die from prostate cancer.” They also criticize the across-the-board recommendation, and that PSA testing should be approved for high-risk populations, such as men with a family history of prostate cancer or men of African descent.

Dr. Otis Brawley, chief medical officer of the American Cancer Society, thinks the USPSTF got it right. He believes that more than one million American men were needlessly “cured” of their prostate cancer over the last 20 years. Writing in support of the USPSTF recommendation, he points out that

Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively. As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause.

Personal decisions

The USPSTF was asked to do some heart-rending calculus: What is one prostate cancer death prevented worth?

To the person whose life it is, and his family, the answer is simple: priceless. The answer will be different for men whose prostate cancer was identified by PSA testing, who were treated unnecessarily for a cancer that never would have threatened their health, and who can no longer get erections, who need diapers or other aids to cope with urinary incontinence, or who have long-lasting bowel problems.

“I explain to my patients that getting a PSA test may lead to a treatment that will remove a cancer from their body but that may cause erectile dysfunction and incontinence,” says Dr. Komaroff, “They often reply that the side effects are worth eliminating the cancer. Then I tell them that there is only a small chance that their cancer will actually spread and cause suffering, but that I do not have a test that can determine what the chance is. Some say, ‘Then take it out.’ But others say, ‘Then let’s just watch it.’ I think the patient needs to participate in the decision about PSA testing.”

The USPSTF recommendation won’t be the last word on PSA testing. Men still have a choice.

I’ve been telling my doctor for years that I don’t want it. If you do, talk with your doctor. But before you get your blood drawn, realize that a high PSA might start you on a path to biopsy and treatment that will likely cause more harm than good.

Comments:

  1. dodo

    if the treatment is more harm than the cancer itself, I prefer to not have the treatment. I’ll try some alternative that safer than treatment, because it’s better than doing nothing…

  2. Yuri Case

    Its amazing news that in this day and age that LESS is the right choice over MORE MORE MORE. Now lets hope that MDs and DOs follow through with this and take action. While I’m watching the olympics and seeing all of these prostate commercials, I’ll shake my head.

  3. Elizabeth (Aust)

    It’s great to see some concern for men with cancer screening, shame there is zero respect for informed consent in women’s cancer screening. We see the shocking overuse of the pap test to IMO, generate high profits from over-treatment…and then there’s the black cloud that hands over breast screening.
    Take a look at the new Dutch cervical screening program, focused on what’s best for all women, not vested interests. Their 7 pap test program, 5 yearly from 30 to 60 will be replaced with 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV positive and at risk from cc will be offered a 5 yearly pap test. Those negative, the vast majority, will be offered the HPV program and there is a long overdue self-test option, the Delphi Screener. (also being used in Italy, Singapore and elsewhere) Those negative and monogamous or no longer sexually active can forget all further testing. This will greatly reduce invasive pap testing, potentially harmful over-treatment and is more likely to prevent these rare cancers. The Dutch are light years ahead of most countries where programs are controlled and influenced by vested and political interests. The Finns also have a 7 pap test program and have the lowest rates of cc in the world and they and the Dutch refer far fewer women for colposcopy/biopsies.
    Then we have breast screening – the Nordic Cochrane Institute concluded 10 years ago that it is of little benefit, but leads to significant over-diagnosis – they now say it’s marginal benefits and that 50% of screen detected cancers are over-diagnosed. Yet we keep urging women to screen…IMO, all for the benefit of vested interests.
    I think the dishonestly and lack of proper ethical standards in women’s cancer screening is disgraceful and reflects very poorly on the medical profession.
    In the States women are routinely coerced into elective cancer screening and denied reliable birth control until they submit…and this is allowed to continue. That conduct would amount to professional misconduct here.
    It’s clear to me a double standard exists in medicine and paternalistic attitudes are still alive and flourishing.
    Needless to say I did my own research and rejected both programs….informed decisions.

  4. Tim Bartik

    Your numbers are even more off than the numbers in the USPSTF report. For every 1000 men SCREENED there will be 200 to 300 cases of impotence? Perhaps you mean that for every extra 1000 men TREATED for prostate cancer there might be 200 to 300 cases of impotence. The USPSTF made a similar although smaller error in saying there might be 40 cases of impotence or incontinence per 1000 men screened. This 40 figure represents the extra side-effects of screening only if the unscreened group had no prostate cancer or side effects, which is untrue. If one believes the European study, the true ratios are this: for every 1000 men screened, there will be one life saved from prostate cancer, which should be compared with 8 to 13 extra men with serious side effects from prostate cancer treatment.

    • KeLvin

      No it isn’t.A diet HIGH in dairy products is thguoht to be a possible risk factor for prostate cancer. Note the words high’, thguoht’ and possible’.And a risk factor is not a cause. Insurance companies regard being male’ as a risk factor for having a car crash, but being male doesn’t cause car crashes.The greatest risk factor for prostate cancer is getting older. It’s extremely rare in men under 50; over 80% of men diagnosed with it are over 65 and half of all cases occur in men over 75. It’s so rare in young men that there are no statistics available for the disease incidence in men under 35.

  5. Marielaina Perrone DDS

    There are definitely two arguments to this subject but I would prefer to err on the cautious side.

    • Anthony Turley

      But what does “cautious” mean? I have PC. At age 46 I had my third digital rectal exam, or “Prom Night Redux” as I like to call it, which was normal (again), and my first PSA: it was 138. My biopsy showed a Gleason of 9. I had a radical prostatectomy on 12-9-09, upon which my urologist found that the cancer was “not contained,” and then I enjoyed 6 weeks of radiation. My oncologist says I have about an 85% chance that the cancer will metastisize, and that my most likely outcome is death from cancer by 2016. Isn’t my life worth a blood draw for a test that costs $45? And why wasn’t a “baseline” done on me when I turned 40? I’m convinced that if the PSA had started at age 40 and been repeated biannually for me, my course would have been much better. I think the decision by the panel is reprehensible, because it tells guys like me, “we can accept one in 1,000 deaths, because some patients and some doctors get too aggressive when PC is found any way.” Why not deal with the over-aggressive treatment as the problem, rather than choosing to accept losing several hundred lives per year over a $45 test?