A furious debate has erupted over a widely-used method of detecting prostate cancer. The test is PSA screening — for “prostate-specific antigen” — a blood test that can help a cancer specialist advise a biopsy and possible surgical or radiation therapy.
The U.S. Preventive Services Task Force, an independent panel of nongovernment experts created by the U.S. Public Health Service and authorized by Congress, recommended in a draft report on Oct. 11 that PSA screenings no longer be used for screening men who have no symptoms, regardless of age, race or family history. It said the test does more harm than good.
Many urologists staunchly defend PSA screenings as a useful tool in saving lives. Surviving-patient groups are denouncing the task force and calling for it to be disbanded.
In Maine, Terry Kungel, president of the nonprofit Maine Coalition to Fight Prostate Cancer, defends offering PSA testing along with counselling as to the pros and cons of the procedure. Mr. Kungel wrote to the task force, with copies to Maine’s congressional delegation, that its approach was “deeply flawed” and would “likely lead to unnecessary deaths.”
He added that the panel included no urologists, no oncologists involved in prostate cancer and no patient involvement and that its “single, simplistic, one-size-fits-all answer for everyone is bad science and bad judgment.”
Mr. Kungel also wrote that the task force recommendation, if it stands, will “likely lead to reimbursement being dropped for all PSA tests.” A task force spokesperson says the new Affordable Health Care Act prohibits ending the reimbursement.
The Eastern Maine Medical Center, the Maine Medical Center in Portland, the American Cancer Society and the American Urological Association all continue to advise offering PSA testing, but always in consultation with the patient and discussion of the pros and cons of testing and treatment.
Men fear prostate cancer, and with good reason. The Maine Medical Center says that one in six men have prostate cancer and that it is the second leading cause of cancer death in men after lung cancer. Last year, 1,130 men in Maine were diagnosed with prostate cancer. The American Cancer Society puts the mortality rate at 14 percent of those diagnosed.
The mysterious disease has no known cause and has no symptoms in early stages. Some cancers never grow, some grow slowly and never cause problems and some are aggressive and life threatening. Digital rectal examination may suggest the possibility of cancer. But neither a PSA test or a subsequent biopsy — expensive and painful with perhaps 10-15 needle insertions through the rectum — can tell whether a cancer is inert or growing or at what pace.
Until current promising research produces a more accurate diagnostic tool, that may leave surgery to determine whether surgery was necessary. And, says an American Cancer Society paper, “Treatments for prostate cancer can have a lot of unpleasant side effects like incontinence and impotence that can really affect the quality of a man’s life.”
All these uncertainties place a heavy burden on the patient. With a diagnosis of possible cancer, he may well choose biopsy and possible surgery or radiation on the chance that they may save his life, even knowing that his cancer may be so slow-growing that it is no threat.
An article in the current issue of the New England Journal of Medicine says that 2009 reports of two major PSA screening trials “create more confusion than clarity.” It says a U.S. trial showed no mortality benefit from screening, and a European trial showed a small reduction in prostate-cancer-related mortality, but also that large numbers of men received aggressive treatment to little benefit. Another article describes the question of screening for prostate cancer as “the controversy that refuses to die.”
Many people live by aphorisms such as “Better safe than sorry,” and “An ounce of prevention is worth a pound of cure.” Applied to the use of PSA tests, these sayings may ease the worries but add to national health care costs, amounting to a pound of prevention and an ounce of cure. The tests lead sometimes to saving a life, sometimes to distressing side effects and sometimes to unnecessary biopsies and therapy.
There presently is no easy answer.