Men who got regular PSA blood tests were 21 percent less likely to die of prostate cancer, according to a European study published in the New England Journal of Medicine Wednesday. The new research probably won’t change the current screening guidelines for American men, but the findings could reopen the controversy -- and confusion -- over prostate cancer screening.
“What am I am supposed to do?” my physician lamented during my most recent physical exam. “All my male patients are refusing PSA tests. How do I check for their prostate cancer risk?”
It has become a common concern. Ever since the Food and Drug Administration approved it in 1987, the Prostate-Specific Antigen blood test has been controversial. Many experts condemned it as unnecessary, or even dangerous, for most men. Many medical organizations including the American Cancer Society, the American Medical Association and, most recently, the U.S. Preventive Services Task Force have not recommended it. General practitioners often ordered the test, usually without a discussion of the implications, to most men who came into the office.
Finally, however, many patients have gotten the message and are saying no on their own.
This trend will likely continue despite results from the European Randomized Study of Screening for Prostate Cancer that followed 182,000 men for 11 years. More fundamentally, it renews the question: How can a cheap and painless blood test for a potentially deadly cancer be unnecessary -- or even dangerous?
Prostate cancer differs substantially from most other cancers. Still, many doctors and patients insist on putting it into their mental box called “cancer” where the response is always “find it early and cut it out.”
Make no mistake, it can be a killer. At least 28,000 men in the U.S. will die from prostate cancer this year. But 241,000 men in this country will be diagnosed with the disease and most of them -- whether they are treated or not -- will likely survive to die of something else.
Prostate cancer comes in at least two forms. One is the killer; the other is a slow-growing type of cell most men get if they live long enough. Studies of men who died of other causes found that 30 percent of those 50 and older and 70 percent of those over 80 have prostate cancer and never know it. Medical science cannot distinguish between the killer form and the far more common one that can be left alone.
That is where the PSA test comes in. It is not a test for cancer, but for normal prostate tissue, which can be enlarged for several reasons. If the PSA is elevated, the doctor will order a needle biopsy. Because prostate cancer is so ubiquitous, the biopsy will often find some.
Then the patient and his doctor face a dilemma. Whether the treatment is surgery, radiation, hormones or a combination, it often comes with serious side effects including impotence, incontinence and bowel problems. Often men who need no treatment follow this path and end up with the side effects. Millions of American men have. It is difficult to find men who will admit suffering embarrassing side effects that may not even be necessary. In fact, most often they will call themselves lucky to be “a cancer survivor” -- even if it is from a cancer that may never have hurt them.
The latest European study found that to prevent one prostate cancer death, 1,055 men had to be screened and 37 men were diagnosed. That means that 36 men were eligible for treatment that may not have been necessary and may have left the men with distressing side effects.
In addition, a similar study of U.S. men has found no survival advantage from routine screening. An editorial in the current New England Journal of Medicine where the study appears concludes current guidelines should not change.
As for my physician’s question, he still has the old digital rectal exam to find lumpy spots, which was how prostate cancer was found before PSA. And scientists are looking hard for some genetic marker that will distinguish the truly dangerous prostate cancer.
Until there is better diagnosis, any man would be advised to have a serious discussion with his physician about whether he wants his blood to be tested for PSA. The test could easily start him down a path he does not want to follow.
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