Prostate Cancer Screenings Not Recommended

The U.S. Preventive Service Task Force recommended against screening for most healthy men, concluding that it causes too much anxiety and leads to unnecessarily aggressive treatment including surgery. Many doctors and patients say they will continue the prostate specific antigen (PSA) blood test.

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NEAL CONAN, host: Last week, we talked about life after prostate cancer surgery, but since then, prostate cancer's been all over the front page. Late last week, word leaked that the U.S. Preventive Service Task Force would no longer recommend routine screening. This week, the studies to support that conclusion came out, along with op-eds that challenged it. If the new screening recommendation has you scratching your head, give us a call: 800-989-8255. Email: talk@npr.org. You can also join the conversation on our website. Go to npr.org and click on TALK OF THE NATION.

Joining us again to talk about prostate cancer and the recent recommendation is Tara Parker-Pope, editor of The New York Times Well blog. And nice to have you back on TALK OF THE NATION.

TARA PARKER-POPE: Sure. Happy to be here.

CONAN: And as I understand it, the fundamental finding of the task force is that most of the time, prostate cancer grows so slowly, that most men will never know it's there. But if they do find out they have cancer, it is very, very difficult not to do anything about it.

PARKER-POPE: That's exactly right. I've interviewed several men who say that, you know, the moment your doctor looks you in the eye and says you have prostate cancer, you know, you can't really get that thought out of your head. And your sort of fast reaction is, well, we've got to get it out. And what we know is that, often, you probably don't have to get it out. But it's not really about what's happening at that individual patient level. What we're seeing is that when you think about the risk and benefits of a screening program, you have to look at large populations.

You need to see: Are we making a difference? We're finding cancer early, but are we saving lives? And the resounding conclusion I know from several studies is that no, we really probably are not saving lives. If we are, it's so few lives, it's dwarfed by just the enormous pain and suffering we're causing men by testing - by doing this screening test.

CONAN: Enormous pain and suffering, because they then go have procedures of various types, and men end up impotent, incontinent or both.

PARKER-POPE: Right. And it's really from - it's the stress of being told you might have cancer from having a high PSA rating. Men go in and get these biopsies, which are not inconsequential. They can be uncomfortable, and they can actually lead - I've actually heard from several readers where, you know, men have ended up in the hospital with infections from a biopsy. That is a rare complication, but it does happen. And once you get the biopsy, if it's clear and you've still got the high PSA, your doctor's going to say, well, I'm not confident. Come back again. Come back again for repeat biopsies.

And if you do find cancer, you know, a biopsy's 12 or 15 sort of quick samples from the prostate. And if you find cancer in even one of those cores, then you're suddenly in this world of, you know, do I make a decision to undergo treatment, which might leave me incontinent - will probably leave me incontinent and impotent, at least for a little while.

CONAN: And among the controversies here is the fact that the board reached this conclusion two years ago, and because of their experience with the uproar after making similar recommendations on breast screening, breast cancer screening, they waited two years till they could assemble the science. In the meantime, tens of thousands of men may have had procedures they didn't need.

PARKER-POPE: Yeah. And I guess - I mean, I think it is probably prudent to, you know, get the science right, and that's what the chairman of the task force has said. Should we have had this debate two years ago? Maybe. But would people have heard it in the midst of the mammography recommendations? You know, I don't know that we can second-guessed that decision, because the truth is the recommendation is out now, and plenty of men are still going to continue to get PSA screening because they find it very difficult, as do their doctors, to give up this idea that they really truly believe earlier is better. Find cancer early, it's better. It's a really difficult concept to grasp that that's not always the case.

CONAN: And we've seen all kinds of people come out in the past couple of days and say, wait a minute. This is a test that saves lives. Who are you kidding? Why are we stopping this?

PARKER-POPE: Yeah. And it's interesting - I mean, there is a legitimate debate here about what these large studies have shown. The U.S. study pretty clearly showed it did not save lives, but you can, you know, poke holes in that study for sure. The European study, not quite as clear. There was a lot of variations and a lot of problems with the data in that study, as well, that showed that maybe one in 50 men is helped. And the argument is quickly - well, if at least one life is saved, then shouldn't we do it? But you really have to kind of calculate the suffering that is caused over large groups to, you know, to make that decision. You know, one in 50, is that a reasonable trade off for, you know, as Otis Brawley at the American Cancer Society said, the PSA test is 50 times more likely to ruin your life than it is to save your life.

CONAN: We're talking with Tara Parker-Pope of The New York Times' Well blog. If you have questions about the recent recommendations on prostate cancer screening, give us a call, 800-989-8255. Email talk@npr.org. And Tom is on the line from Syracuse.

TOM: Hi. I just had a comment. I'm a prostate cancer survivor. When I was 52, I had benign prostate hyperplasia. They did a prostate biopsy. It was negative. The PSA was .5. Then when I was 55, the PSA went up to 4.5. They did another biopsy, and I had three out of 10, or three out of 12 cores were positive. And within six months, I had my prostate removed, and now I'm a prostate - I'm 62 now. It's five, six years later. I am cancer-free, and I'm not worried about it. So I just don't know what this big uproar is about.

CONAN: So from your point of you view, Tom, it saved your life?

TOM: Yeah. It saved my life, or it just saved me a lot of worry, you know, because, you know, the prostate cancer in general doesn't grow that fast in most people, but I watched my uncles died of it. So it was 30 years ago, but still, that was a nice lesson in life.

CONAN: And have you had side effects?

TOM: No. No. Luckily, I had an excellent surgeon, and the side effect, relatively impotent. I'm not incontinent, and I have no problems at all.

CONAN: All right, Tom. Thanks very much for the call.

TOM: You're welcome.

CONAN: Tara Parker-Pope, that is the conclusion a lot of people are going to come to.

PARKER-POPE: You know, that's interesting with that caller because what he - what we heard is that he had a PSA test led to the biopsy. It's three out of 12 or three out of 14. He wasn't sure. But from the very little information he shared there, he sounds like he might have been a candidate for watchful waiting because less that a third of the - a third or fewer of the samples were positive, is one of the criteria. There are others, and I don't know if that fit with him, but it's a question, you know, how often is the idea of waiting to see if the cancer progresses, you know, offered to men. And I think this idea of, I don't want to worry - and this is why you have to ask yourself, do you want to get on this path? Once you take the test, you are more likely to be harmed than helped by it.

But for some people who have a family member they have seen die of prostate cancer, who are just very concerned about it, it might be the right choice for that man. And so I don't think we're saying that the individual should not get a PSA test if it's a reasonable decision he makes with his doctor. The issue is, should we be screening large numbers of healthy men when, clearly, a lot of harm is being done to these men, and that's the debate.

CONAN: So if there is a history of prostate cancer in your family, maybe you ought to be tested, maybe if you're not healthy?

PARKER-POPE: It depends on what that history is. I mean, some people will tell me, I've got a family history, and they'll tell me the story, and their 90-year-old grandfather had prostate cancer. Well, most of our 90-year-old grandfathers have prostate cancer. I mean, it's really common at that age. A strong family history is if you have a father or a close relative that had prostate cancer at a very young age and, you know, died from it.

It's hard to know now what a family history is because, maybe, your 50-year-old brother is diagnosed with early stage prostate cancer, but we still don't know if that cancer was going to kill him. I mean, it's really confusing that you think cancer - it's always best to get it out. But if you take a 65-year-old man, and you give him a PSA test and a biopsy and you find prostate cancer, and you removed the prostate, and he lives for 20 years cancer-free, and he will say, it saved my life. I'm a 20-year survivor of prostate cancer. And at the age of 85, he dies of a heart attack. He will still, you know, the family will say, well, he beat prostate cancer.

Take that same man, don't give him a PSA test. At the age of 65, he lives, again, a nice life. At the age of 64, maybe he has a symptom. He goes to the doctor. Prostate cancer is diagnosed. And at 85, he dies of a heart attack. So he lived a good, you know, he lived the same life. He lived the same 20 years. He had - he lived with prostate cancer, but he died at 85, and that's what's hard to - we hear these survival rates. I survived for nine years. I survived for 20 years. Survival rates are different than mortality rates. Well, did people die at the same age they would have with or without the test? And that's what this studies certainly suggest that they do.

CONAN: Let's get another caller in. This is Will. Will with us from Covington in Kentucky.

WILL: Yes. I'm calling to ask - you're speaking to all the ramifications. If you have this test, then you're going to have the biopsy, then you're going to have surgery. Well, the PSA - in my case, the PSA velocity is a term - if you have a regular PSA test, and it keeps going up, that could be a sign of cancer, and I want to know about it. And it's got nothing to do with treatment. Treatment - you need to split this off. Whether you decide to have a biopsy, which I didn't at first, or a surgery or something like that, that's farther down the road. So I think you're lumping all this together and causing a burden of treatment to men and all that. That's the thing. Go ahead and elect to have, you know, the other tests, you know, the other procedures, surgical procedures, that you described versus a PSA velocity test, you know, which - I'm sorry - pre-PSA test, which will show if it's been increasing. How come you're not addressing that? I don't understand.

PARKER-POPE: Well, I would say that, first off, this is the task force recommendations that I'm, you know, discussing today. So I'm not a medical doctor, and I'm sharing with you the information that I've reported and that I've heard from men. The issue of PSA - pre-PSA test velocity; these are useful tools that doctors can use to help patients make decisions and guide them toward decision-making. There's no evidence that they're necessarily changing the equation, that it's making anymore or less difference, you know. Again, we start - we talked about the individual man and the anecdote, and you might find the situation where it seems at least helpful, but that's why we don't rely on the anecdote. We go to these large population-based studies.

WILL: Yeah. There're no the neurologists of part of this committee, part of this panel, what I understand, they're no specialists at all. Is that correct?

PARKER-POPE: I have - that may be true. This is a decision, you know, the fact of the matter is, is that the doctors who make decision about PSA testing or family-practice doctors, not typically neurologists. So most men who get a PSA test get that test from their family doctor.

CONAN: After their annual check up, yeah.

PARKER-POPE: At the annual check up, but, you know, part of this, there's a whole economy around the PSA test. So I think that I have heard, you know, I understand what you're saying and your feelings about the story, and it definitely reflects a strong point of view out there. There are many people who feel as you do. However, I have also interviewed many men who, like you think, live a perfect world. I should be able to have this information and make a decision. And the moment they get the high PSA number and they get the biopsy with, you know, I talked to a man with one positive sample out of 14, and every doctor he talked to said, surgery, surgery, surgery. And a lot of these doctors that are giving us advice, they're telling us about what they know, and they're surgeons, or they're radiologists. I mean, they have their own, you know, sort of experience that they're bringing to the discussion.

I've talked to several men who have really wanted to be considered for watchful waiting programs, and they have to just fight their way into them because they had to search out for a program that would take them because their doctors said, you're crazy. You should take out the prostate. Take out the prostate. One of these men, you know, I talked to him 10 years since he was told to have the surgery, and his PSA is down, his future biopsies have not been positive. Clearly for him, made the right decision to do this, you know, active watchful waiting. It's really not an option given to men very often, I believe.

CONAN: We're talking with Tara Parker-Pope, editor of The New York Times Well blog. You're listening to TALK OF THE NATION from NPR News. And let's go to Dan, Dan calling from St. Louis.

DAN: Hello.

CONAN: Hi, Dan. You're on the air.

DAN: Nice show.

CONAN: Thank you.

DAN: I wanted to know what the additional ramifications of health insurance or perhaps, more specifically, lack of health insurance, how that might play into this. It seems like if you are funding out-of-pocket, and you get the, you know, like, well, OK, you can do watchful waiting or what. It seems like you can sweat out trying to pay for it, or worrying about if it's going to happen to you, and then you have to have your self-funding. I'm just curious about how that angle plays into it.

PARKER-POPE: Do you mean, if you're diagnosed and then you don't get the surgery and then you don't have health insurance when you might need it, is that your question?

DAN: Yes, basically. I mean, it's another segment out there that's getting tested maybe and maybe you're having to do further testing, funding it out-of-pocket.

PARKER-POPE: Well...

DAN: And...

PARKER-POPE: Yeah. I think it's absolutely a fair question in this country where, you know, paying for health care is constantly part of the discussion, and I think that really is a larger issue of how we take care, you know, in a fair way people who need health care. I do think it's important to say that the task force did not consider cost. A lot of people have reacted very strongly, worried that this was just a money decision. Actually, cost is not - this is not a very expensive test. Cost is not factored into it. That said, downstream from the test, you know, all the things that happened as a result of the test are quite expensive. But there is also those economic pressures on keeping the test because huge practices and, you know, skills and specialties have evolved from the widespread PSA testing in this country. So certainly, economic issues are a part of this discussion, but your question about the what if? To me, that's just such a larger issue for everybody who's worried about losing their job and losing their health benefits.

CONAN: Dan, thanks very much for the call.

DAN: Thank you.

CONAN: Let's see if we can go next to - this Doug, and Doug is with us from Traverse City in Michigan.

DOUG: Yeah. I still haven't quite understood what the recommendations are, if it's - now you should be screening for a baseline or don't even have the PSA test at all.

PARKER-POPE: The recommendation is that healthy men should - that routine PSA testing of healthy men is not recommended. This is consistent with some other medical groups. The American Cancer Society has basically said, you know, it shouldn't be routine, but men should have a conversation with their doctor about it and make, you know, an informed decision about the benefits and risks of PSA testing. But the task force has taken, I think, perhaps a stronger stand by saying this is not a good idea to generally screen the healthy population. You know, they don't make specific recommendations. Say, you have a very strong family history...

DOUG: OK.

PARKER-POPE: ...if you have been tested before and you had a positive biopsy, or you've had a history of problems, you're no longer really in that healthy man population, but yet, the recommendation is that if you did sort of routine PSA testing - that happens to a lot of men without their knowledge. They just go to the doctor and the blood work is done and not - it's not even discussed with them. That's what being recommended against.

DOUG: Right. I have a pretty strong history of cancer in my family, and I'm in my mid-40s right now, and I haven't had a physical for a few years. And so it's pretty much just waiting until you have any symptoms before you think about getting a PSA?

PARKER-POPE: Well, I think you have to make - it's very difficult decision for men to make - and I'm sorry to sound pompous - but I think it depends on your family history, on the types of cancer, if there's any connection with those cancers and prostate cancer. You know, people with colon cancer or, you know, a family history, they have to make this decision too. You know, the general recommendation is one screening test at the age of 50. But for people who have it in their family, they start getting screening tests, you know, colonoscopy in their 40s. Same for breast cancer.

So for men, though, what's confusing is that they're saying, well, you'll never going to get screened, not at 40, not at 50, not at 60, not at 70, and that is the recommendation and it's hard. But the reason behind the recommendation is that it's not going to do you - it's probably not going to help you. But you're right. You as an individual, you might come to a different decision and say, you know what? This is bothering me, and I want to get a baseline PSA, and there's nothing about this recommendation that prevents a man from doing that.

CONAN: Doug, thanks very much.

DOUG: OK. Thank you.

CONAN: And good luck to you. Tara Parker-Pope, thanks again for your time.

PARKER-POPE: Thank you.

CONAN: Tara Parker-Pope, editor of the Well blog at The New York Times, with us from our bureau in New York. Tomorrow, the Iranian Quds Force and the D.C. bomb plot. Plus, writer Ariel Dorfman on what's missing from his library. Join us for that conversation. And if you're on Facebook, you can find us there. Go to nprtalk, all one word. This is TALK OF THE NATION from NPR News. I'm Neal Conan, in Washington.

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