Dear Dr. Garner,
Could you please tell me your thoughts regarding PSA prostate cancer screening?
I read the report of the government panel and am not sure what to do.
What is the story?
PSA Question in Queens
Dear PSA,
I agree that the whole thing is very confusing. There has been much conflicting information regarding PSA (prostate-specific antigen) screening throughout the years and now a prestigious task force has issued some very controversial guidelines.
Let’s look at the facts.
A government task force comprised of experts in prostate cancer, preventive medicine, and screening, announced last week its final recommendation on PSA screening for prostate cancer.
The recommendation is not to have men routinely screened for prostate cancer using PSA blood tests. PSA is a chemical found in the blood that is often elevated in people with prostate cancer. It may be elevated in benign (not cancer) cases, such as men with enlarged prostates. This can lead to false positive results (thought to be positive, but are really negative) in which the man undergoes extensive work-up and treatment that is totally useless.
To make matters worse, these unnecessary tests and treatments, such as biopsies and radiation, have harmful side effects associated with them.
I am sure that many of our male readers are currently getting yearly PSA blood levels and do not know whether to continue with the practice.
The task force noted that only one major study found evidence that screening saves lives, and that study has been criticized as not being done correctly.
The task force noted that some men may want to be screened because of family history or other concerns, but that even in these cases. there is reason to hesitate drawing the lab test.
They stressed that patients need to have a detailed conversation with their doctor before the blood test is performed, and that they understand the meaning of a false result.
The past 20 years have seen an increase in the number of health fairs where screening has been performed.
It is estimated that as a result of these well meaning fairs, that one million American men have received unnecessary treatment with numerous bad effects, including bowel injury from radiation, urinary incontinence and impotence, and other serious, life-threatening complications.
Each year 1,000 to 1,300 men die from complications associated with treatments prompted by PSA screening fairs.
Some conspiracy theorists have argued that these fairs were actually money-making businesses for doctors and hospitals because they created biopsies and other procedures that are quite lucrative. I do not believe this is the case. I feel that the reason behind the fairs is meant to help the health of men and prevent their dying from prostate cancer. The information that we have today was not known until recently.
Does the test have any value or is it totally useless? My thoughts are as follows:
• I would not throw out the test altogether.
• Some studies have shown that men who got PSA testing are more likely to survive five years after being diagnosed, compared with those who did not get screened.
• Some studies show that men who are screened have decreased spread of disease.
• The PSA test is not the only test that should be used to evaluate men with prostate cancer. Tests such as digital exam, and ultrasound, as well as clinical history, can be very valuable.
• Doctors should not be using it in isolation, but as a part of the total evaluation of a patient.
Unfortunately, we are missing a better test at this time that could tell us which prostate cancers are more likely to kill, and which ones basically are slow growing and pose no threat to life expectancy.
Why not let the test be drawn and have the doctor and patient look at the whole picture, and decide what to do?
The problem with mass screening is that it is aimed at a general and varied group. Some men, such as African-Americans or those with family history of prostate cancer should have access to the test, as they have a higher risk of developing prostate cancer.
For the general population, many urologists suggest screening at age 40 to serve as a baseline, with follow-up to be determined by doctor and patient. I believe this course is reasonable.
Doctors realize that patients want a quick definitive answer, but this is not possible with the PSA.
Rather than make a blanket statement to eliminate screening, it is better to emphasize that screening should be decided on an individual basis. If only one PSA cancer death out of a thousand is prevented, I am sure that the families of those who have survived because of it would be very happy they went for screening.
In summary, let us not throw out this inexpensive and simple test to diagnose prostate cancer. We should utilize the result better — not at some mass screening at a mall, but through education and rational discussion between doctor and patient.[hr]
Dr. Steven Garner is a Fidelis Care provider who is affiliated with New York Methodist Hospital, Park Slope. He also hosts “Ask the Doctor” on The NET, Tuesdays at 8 p.m. on Channel 97 Time Warner and Channel 30 Cablevision.
