Warren Buffett’s revelation that his prostate cancer was diagnosed with the help of a prostate-specific antigen (PSA) test threatens to reignite controversy that the medical community hoped had been settled last year over the usefulness of the test.
In November, the U.S. Preventive Services Task Force issued a draft recommendation that routine PSA testing be dropped, concluding that the benefits of finding cancers did not outweigh the risks of needless biopsies, and overtreatment that could lead to serious complications like impotence and incontinence. They gave PSA testing a “grade D” rating for healthy men of all ages.
That was controversial because, of course, some men have been saved by early detection via PSA screening. Many more men, the expert panel concluded, had unnecessary biopsies and damaging surgeries for cancers that would never have killed them, because the PSA test isn’t very good at distinguishing between aggressive and non-aggressive cancers.
What wasn’t controversial, however, was the idea of dropping routine PSA testing in men over 75. That 2008 recommendation reasoned that prostate cancers detected in men of such an advanced age were usually slow growing, and that given life expectancies, men that age and older would be much more likely to die of something else.
Now Warren Buffett, 81, who happens to be one of the wealthiest and most famous men in the United States, has received a PSA test that led his doctors to initiate treatment for prostate cancer. It’s just the sort of scenario that leads many people to question the guidelines, which drives some experts crazy.
There are always exceptions, explained Dr. Michael Barry, president of the Informed Medical Decisions Foundation and a clinical professor of medicine at Harvard Medical School. But the recommendations, especially for men over 75, are still very sound.
“It is hard for men to benefit if they have less than 10 years of life expectancy,” he said. “Now, like Lake Wobegon, we all hope we will do better than the average… But there is strong scientific consensus that harms outweigh the benefits. That does not mean you can’t find an individual who may benefit, it means the number harmed far outweigh the occasional man who does (benefit).”
Dr. Michael LeFevre, co-vice chair of the U.S. Preventive Services Task Force, professor of family and community medicine at University of Missouri Columbia, agrees with the risk/benefit argument and says that's why the panel made the recommendation it did.
He added, if an 80-year-old man who read about Buffett came to his office and demanded a PSA test, "what I am going to say to that man is 'I don't recommend screening. The chance you have prostate cancer is very high, somewhere between 25 and 50 percent of men your age have it. The problem is, I can't make you live longer or better by trying to find it. If I screen you, I may find it, but likely you'll suffer complications or even die from effects related to the treatment.'"
The issue is one that pits the individual against the collective numbers. Nobody wants to be that one guy who opted not to be tested only to find out he was the outlier who could have been saved. That’s why Barry and some other experts hedge slightly on the recommendations for younger men, arguing in a New England Journal of Medicine opinion piece that “evidence of a possible small but finite benefit from the largest trial would best support a grade C recommendation for men 55 to 69 years of age.”
A grade C is a recommendation against routine screening, but suggests doctors and patients consider it on a case-by-case basis.
But, Barry told msnbc.com, “at some point the chance of doing harm is so great it overwhelms the slender chance of benefitting and although this has been an area of great controversy, there is consensus that after 75, the benefits do not come anywhere close.”
The prostate-specific antigen test that men have come to expect at a certain age is not a good screening tool and does not routinely need to be done, according to the U.S. Preventive Services Task Force. NBC's Nancy Snyderman reports.