A urologist responds to the new prostate cancer screening guidelines

U.S. Panel Says No to Prostate Screening for Healthy Men” was the title of an article on the front page of the New York Times on October 6, 2011.  The article goes on to suggest that healthy men should no longer receive a PSA blood test to screen for prostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided.

Two years ago the very same task force recommended that women in their 40s should no longer get routine mammograms, setting off a firestorm of controversy. That recommendation was met with strong resistance by many cancer organizations, women and their doctors, many of whom continue to ignore it.  The recommendation to avoid the PSA test is even more forceful and applies to healthy men of all ages.

One in six men in the United States will eventually be found to have prostate cancer, making it the second most common form of cancer in men after skin cancer. An estimated 32,050 men died of prostate cancer last year and 217,730 men received the diagnosis. The disease is rare before age 50, and most deaths occur after age 75.

So what do Joe Torre, Bob Doyle, Jerry Lewis, John Kerry, General Norman Schwarzkopf, and Mayor Rudy Giuliani have to say about PSA testing?  All of these men have had PSA testing which led to the diagnosis of prostate cancer and have received successful treatment their disease.  These men are among tens of thousands of men who believe a P.S.A. test saved their lives.  Some of these men, which include Mayor Giuliani and Joe Torre are advocates for PSA testing and plan to fight the recommendation.

The PSA test, routinely given to men 50 and older, measures a protein — prostate-specific antigen — that is released by prostate cells, and there is little doubt that it helps identify the presence of cancerous cells in the prostate. But a vast majority of men with such cells never suffer ill effects because their cancer is usually slow-growing. Even for men who do have fast-growing cancer, the P.S.A. test may not save them since there is no proven benefit to earlier treatment of such invasive disease.

So what am I recommending for my patients and myself?

This report by a panel of experts (the chairperson is a pediatrician and probably has never seen or diagnosed a patient with prostate cancer) is certain to cause confusion and anxiety among men and their doctors, and reignites a debate about the benefits and risks of screening tests.

The recommendations affect more than 44 million men age 50 and older who typically are candidates for the PSA test.

Whether to be screened for prostate cancer is still a decision that each man must make for himself with the advice of a doctor he trusts, usually the man’s primary care physician or a urologist.

The panel’s advice is based on studies of healthy men. Men who have symptoms related to prostate health such as painful urination or blood in the urine should seek out medical care from their doctor. Also men with a strong family history of prostate cancer may have more to gain from screening than men at low risk, so they also should discuss the issue with their physician.

Finally, my advice to a man who already has a diagnosis of prostate cancer and has chosen to follow a course of watchful waiting should continue to undergo PSA testing, which can help doctors determine whether cancer has returned or is spreading.

I recommend to my patients that they begin testing on an annual basis after age fifty.  However, if they have a close family relative, father, brother, or uncle with prostate cancer, that they begin testing at age 40.  Also, African-American men should also begin PSA testing at age 40 because of the increased risk of prostate cancer among African-American men.  I do not recommend PSA testing in men with less than 10 years life expectancy.

The PSA test is a non-invasive, inexpensive test that is helpful in detecting early prostate cancer.  Each man should have a discussion with his doctor and determine if PSA testing, diagnosis and treatment is right for them.

Neil Baum is a urologist at Touro Infirmary and author of Marketing Your Clinical Practices: Ethically, Effectively, Economically. He can be reached at his self-titled site, Neil Baum, MDor on Facebook and Twitter.

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  • http://pulse.yahoo.com/_KGG72P5DEGYYMOGVYAP44TWDKM Paul S

    This isn’t really a response to the new USPTF recommendations. Dr. Baum essentially just said he has read the recommendations but is disregarding them. His only real argument for dismissing them is that the chairman of the task force is a pediatrician as if that means the task force cannot analyze studies on the subject because one person on the task force takes care of children.  As a young physician I totally agree with discussing with my patients about risks/benefits of PSA screening. However, what I haven’t figured out yet is what to recommend for those patients who refuse to make a decision and will go with whatever the doctor recommends or to those that would like my opinion (“If this was you or your father…”) before making a decision. I was hoping this post would explain why a urologist thinks the task force’s recommendations are misinterpreting the data instead of summarily dismissing them and telling us instead what he recommends to patients.

  • elizabeth52

    I wouldn’t accept a recommendation to have cancer screening without doing my own research – screening is so political and loaded with vested interests. I found in cervical and breast cancer screening the evidence was far less clear than it was made out to be and risk information is basic or non-existent. There’s also a coercive and disrespectful attitude in women’s cancer screening – we’re expected to “do as we’re told”…like ignorant sheep.

    I don’t think it would have been possible to have a fair discussion with my GP without having done the research first, because I wouldn’t have known what questions to ask…few women understand the chance of being helped by cervical screening is very low, while the risk of a false positive and unnecessary biopsies and treatments very high…

    Women are told that with screening 70% or 90% of cancers can be prevented, but are never told that the lifetime risk of this cancer is 0.65% and that fewer than that number can be helped by screening – take out false negatives and consider that other factors are playing a part in the fall in the incidence rate – less than 0.45% can be helped…the 90% suddenly sounds less impressive.

    We might be told the test is not 100% reliable, but not told the test is intrinsically unreliable and cannot distinguish between the rare lesions that will go on to invasive cancer and the ones that won’t…and that everyone gets “treated” – so testing results in very high over-treatment rates that can harm women and leave them with problems – cervical damage from LEEP and cone biopsies can mean premature babies, the need for c-sections etc

    Women are NOT told the risk of a false positive is very high – 95% lifetime risk of referral for American women and 77% for an Australian woman. We’re not told that annual and 2 yearly testing is over-screening and carries more risk for no additional benefit.
    We’re not told – that NOT one country in the world has shown a benefit from testing those under 30, but all have evidence of harm – and that young women produce the most false positives.

    So, in my opinion, unless you’re aware of these facts and have an opportunity to assess your own risk profile, you cannot make an informed decision to screen – you’re screening in ignorance, having been misled by the “facts” as presented to you, as a result of blind faith in the benefits of screening or against your will or with no consent at all. (women coerced and pressured into screening)
    The same problems are found in breast screening…please, do your reading!
    http://www.cochrane.dk/

    I find it totally unacceptable that women get a biased, misleading and incomplete presentation of the risks and benefits of screening. The attitude appears to be, every woman must screen regardless of facts and informed consent. That is totally unacceptable – informed consent applies equally to men and women.
    At least men are fortunate the facts have emerged early and their right to make an informed decision is respected…they’ll have the facts that will enable them to have productive discussions with their doctors…women are still waiting – most are simply ordered into testing.

  • James deMaine

    The testimonials of public figures who believe that their lives have been saved by prostate cancer treatment are certainly interesting, but they should not persuade us or a Urologist to basically disregard the evidence about PSA.  Yes, the test is inexpensive but the further evaluation and treatment can be expensive emotionally, physically and dollar-wise.  A good friend had his PSA checked last year.  It was elevated and a biopsy showed cancer with a mid-level Gleason score.  Surgery was recommended, but because of his age and cholesterol a cardiac treadmill test was done.  Because of flipped t-waves a cardiac cath was done.  Because of that, a triple bypass coronary graft was done.  A Cardiologist friend later questioned whether any of that workup and treatment was indicated in this man with no cardiac symptoms.

    After recovering from the bypass surgery, my friend went on to a “nerve sparing” robotic prostatectomy.  Well, the nerves could not be spared.  He suffered both impotence and incontinence.  The latter required placement of a pneumatic urethral sphincter that he will have to use for life.

    We as physicians try to be objective, but I’m afraid when we ignore the evidence we are anything but.

  • Anonymous

    And for an opposing take on this subject, consider the book, ‘The Big Scare: The Business of Prostate Cancer’ by Dr. Anthony Horan (not a pediatrician, but a urologist himself who has likely seen and diagnosed his fair share of the disease). Dr. Horan suggests that 94% of cancers detected with the routine PSA test would not cause death before the age of 85, adding: “More men die in car accidents than of prostate cancer each year”. 
    Dr. Michael Barry (also not a pediatrician, but a prostate cancer researcher at Massachusetts General Hospital and Harvard Medical School) seems to agree with Dr. Horan, too, as he wrote in the NEJM:

    “Serial PSA screening has at best a modest effect on prostate cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective, but whether it does more good than harm.”

    Or for some graphic descriptions of the brutal life-altering consequences of prostate cancer treatment, read Dana Jennings (not a pediatrician either, but a New York Times reporter who started writing about his own experience as a patient with Stage 3 prostate cancer back in 2008). He wrote:

    “The cancer itself never did any damage. It was the treatments that razed me – the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes.”  Jennings recommends another book, ‘The Invasion Of The Prostate Snatchers’ co-written by cancer patient Ralph H. Blum and Dr. Mark Scholz (you guessed it, he’s not a pediatrician either, but a real live oncologist). These authors claim that “nearly all prostate cancers are overtreated”. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.”   More on this at   http://ethicalnag.org/2009/12/20/profit-before-patients/

  • hugh nelson

    Ethically, Neil Baum should recuse himself from any public comment on this issue because of his financial interest in the status quo.  Joe Torre, Bob Doyle, Jerry Lewis, John Kerry, General Norman Schwarzkopf, and Mayor Rudy Giuliani have to say that the PSA saved their lives in order to justify to themselves all the costs and pain,  sexual dysfunction and incontinence that they may have to suffer.Lets leave public health recommendations on screening to the experts so money gets spent on priorities such as improving the abysmal rate of childhood vaccination in the USA.

    • Anonymous

      Agreed.  Credibility =nil.

  • Anonymous

    My father had his first PSA done at age 50.  His first biopsy followed right after–negative for cancer.  Since that time he has PSAs over and over and over, and got a second set of biospies 5 years ago–negative.  He just saw the urologist for, guess what, a high PSA.  This time he is to repeat it in 6 months.  Maybe this particular urologist has his student loans paid off. My dad is 73 and healthy except for a few holes in his prostate from his biopsies.
    I just turned 50 and when my PCP and I discussed a PSA last year, hell no was my answer.  I did, however, get a colonoscopy, a screening test which, unlike PSA, has been shown conclusively to decrease suffering and death as promised.
    Don’t believe the urologists’ spin.  PSA is a lousy test, known to be so for years by us family physicians. Early mammography is also a lousy test.  But do get screened for colon cancer.

  • Joe Kosterich

    The simple fact is that the PSA is not a good screening test because of poor sensitivity and specificity. The man who has his life “saved” has won the lottery. Medicine needs to be better than offering a lottery to people

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