A federal panel's controversial recommendation that healthy men older than 50 avoid a PSA-based prostate screening test is drawing scorn from some doctors.
The U.S. Preventive Services Task Force, an independent panel of medical experts, evaluated studies involving 300,000 men conducted in nine countries, including the United States, to issue its determination that PSA screenings, which measure prostate-specific antigen levels, do more harm than good. The panel concluded that while the PSA test can point to the presence of cancer, it cannot distinguish aggressive cancers that kill quickly from the vast majority of prostate-cancer cells that grow so slowly that men will die from other causes.
Proponents of the test argue that it has saved countless lives by providing early diagnosis of a silent cancer, adding that the screening is especially important for African-American men, who are more than twice as likely as white men to die from prostate cancer.
"It would be a major setback if men only saw a headline that says 'Don't Get a PSA Test,' " said Dr. Gerald L. Andriole Jr., chief of urologic surgery at Washington University in St. Louis. Andriole is a principal investigator of one of the clinical trials the federal panel analyzed during its evidence review. Preliminary results from the trial indicate that routine PSA screenings do not lower prostate-cancer deaths among men ages 55 to 74. "There are many men who do benefit from PSA testing," Andriole said. "To totally ignore it sets the hands of progress back."
The American Urological Association acknowledged that not all prostate cancers require active treatment, but by "disparaging" PSA testing, the panel did a "great disservice to the men worldwide who may benefit." The Maryland-based association represents more than 18,000 urologists worldwide.
Dr. Marc Siegel, a practicing internist and author of The Inner Pulse: Unlocking the Secret Code of Sickness and Health, called the panel's recommendation "reckless" in an opinion column published by USA Today.
Despite the test's high error rates, "PSA is all we have, and we would be fools not to use it, as the panel recommends," Siegel wrote. He agrees that a new test is needed but tells The Root that in the meantime, PSA testing is useful, "especially in the African-American community because there is a high incidence of prostate cancer."
But some doctors support the government panel's recommendation. The common perception that PSA-based screening reduces deaths is not supported by the science, said Dr. Michael L. LeFevre, co-vice chairman of the USPSTF. "That is a hard conclusion to accept," LeFevre said during an Oct. 14 conference call. "But that is what the best science is telling us."
Dr. Otis Brawley, chief medical officer of the American Cancer Society, said that he feels vindicated by the panel's call for informed decision making, which matches what he's been saying for decades. "What has happened for the last 20 years is people have lied. People have exaggerated, for various reasons, and people have actually criticized me for simply saying what is scientifically known," Brawley said. At 52 and African American, he's at higher risk, but — like many internists and urologists — he skips PSA screening.
The panel found that 90 percent of men diagnosed with prostate cancer underwent treatments with the potential to cause serious harm. For every 1,000 men who underwent surgery to remove prostate cancer, five died soon after from complications. Up to 70 cancer survivors suffered serious consequences after surgery, such as heart attacks and strokes. Some 200 to 300 per 1,000 treated men were left impotent, incontinent or both.
Prostate cancer is the most commonly diagnosed non-skin cancer among U.S. men. Rarely found in men younger than 40, it is the most common cause of death from cancer in men older than 75, according to the National Institutes of Health.
Awareness programs large and small have taken root, aiming to nudge men into action, and billions of dollars are spent each year on testing and treatment. The National Football League, for example, features prostate-cancer survivor and Pro Football Hall of Fame member Mike Haynes in its awareness campaign. In addition to sponsoring prostate-cancer screening for NFL retirees since 2007, the league this fall intends to run public service announcements encouraging men to get tested.
Andriole suggests regular screening for African-American men and men at high risk because of a family history of prostate cancer. But a heightened obligation would fall on physicians to explain the pros, cons and — given the man's age and other diseases — likelihood that the cancer would be lethal. "Every step should be approached with discussion with the patient of the risks and benefits of proceeding further," Andriole said.
He said that he'll submit his dissent to the recommendation as a public comment (the panel will be accepting public comments until Nov. 8).
Brawley said that he has no problem with an informed man deciding to move forward with treatment. "My problem is men are not informed, and men are, in many instances, duped."
He traces his outspokenness on the matter to the summer of 1997. President Bill Clinton had just apologized for the Tuskegee syphilis study, saying that "our nation broke the trust with our people." A week later, Brawley was in the audience during a business-plan presentation at a National Cancer Institute-designated cancer center.
The marketer showed slide after slide, explaining the dollar value of free publicity the center would get by hosting a free PSA screening at a mall and the resulting "bump in business." Among the 1,000 men screened over age 50, the marketer projected that 140 would have an abnormal reading, Brawley recalled, but 10 would lack proper insurance. The cancer center would bill $3,000 per man for tests to determine why 130 had abnormal results.
"I asked the guy, 'How many lives are you going to save?' He said, 'I can't give you any statistics on that. No one's ever shown this stuff saves lives.' "
In Brawley's eyes, the single-minded focus on the status quo has diverted resources from finding a new test that actually works.
Diedtra Henderson is a freelance science and technology writer whose most recent story for The Root was about new, strident warnings to be added to cigarette packaging.