Black Doctors: On Prostate Screening Controversy
MICHEL MARTIN, host: I'm Michel Martin, and this is TELL ME MORE, from NPR News. Coming up, we're going to spend a good part of the program today on a couple of health issues that have made headlines recently, and that also touch on issues of gender and race. In a few minutes, we'll speak with some of the people behind that classic health guide for women, "Our Bodies, Ourselves." That conversation is coming up.
First, though, we focus on a health issue that is critical for men, and, as in the segment that follows, there maybe some explicit conversation about sexuality or body issues that some might not consider suitable for all listeners. We're talking about that recommendation on prostrate cancer screening by the U.S. Preventative Services Task Force last week. That task force, whose recommendations are closely followed by medical professionals and the insurance industry, recommended that healthy men no longer receive regular blood tests to screen for prostate cancer.
The group says that the prostate-specific antigen test, or PSA, does not save lives and could cause more harm than good by leading to unnecessary tests and treatment. The recommendation set off an outcry from those who point out that prostrate cancer is the second-most common cancer among all men in the U.S. Black men are the most likely to die from the disease. We wanted to talk more about what this recommendation means for all men, and particularly for African-American men.
So, we've invited two prominent physicians who also happen to be African-American. Dr. Compton Benjamin is a urologist at George Washington University. Also with us is Dr. Otis Brawley. He is the chief medical officer and chief scientific officer at the American Cancer Society. I welcome you both. Thank you for joining us.
Dr. COMPTON BENJAMIN: Thank you.
Dr. OTIS BRAWLEY: Thank you for having us.
MARTIN: Dr. Brawley, I'm going to start with you. You agree with the finding that it is time to discontinue the routine use of these tests. In the New York Times last week, you were quoted as saying: "I'm not against prostate cancer screening. I'm against lying to men. I'm against exaggerating the evidence to get men to get screened. We should tell people what we know, what we don't know and what we simply believe."
BRAWLEY: Yeah, that's exactly right. And by the way, the FDA approved prostate-specific antigen for diagnosis. It did not approve it for screening. You have to approve something for screening after you have a study to show that it saves lives, and we don't have that.
MARTIN: So tell me what's wrong with the test and why you believe that it is time to stop recommending routine PSA tests for healthy men.
BRAWLEY: I think that we still should be using PSA, but we have overused it, over-promoted it, and over-promised its benefits. We started using it, by the way, before we started doing the studies to actually see if the thing saves lives, and that's a real problem with medicine. That's something we in medicine frequently do. We get out ahead of the curb, and we end up sometimes hurting people by doing things that we think are right, and 15, 20 years later find out are not right, as is the case with PSA now.
MARTIN: Okay, we're going to ask Dr. Benjamin, before you give us your opinion, tell us a little bit, if you would, about what the PSA is, how it is administered.
BENJAMIN: So, PSA is actually a blood test. It's a 35 kilodalton protein which liquefies on semen. Now, if the protein is only produced in the prostrate, and as a result, if you have your prostate taken out completely, it can then be used to determine whether or not you have prostate tissue - i.e. prostate cancer - or benign prostate tissue that still remains in your body.
MARTIN: So, the test is just a blood test?
MARTIN: And so you believe that it should continue to be used routinely.
MARTIN: Okay. Do you credit the studies that argue the test is too widely used, and therefore this is leading to unnecessary complications for people, unnecessary tests, unnecessary procedures and unnecessary worry for people who really are not at risk? Do you agree with that, or you just don't agree?
BENJAMIN: I think there's some merit to that.
BENJAMIN: However, one of the problems with prostate cancer is that even when we identify that a patient has prostate cancer, we can't truly tell whether or not this patient's going to die with their prostate cancer or die of prostate cancer. And as a result, if you look at things, we are a bit aggressive in terms of treating this disease. But if there were a better test to determine whether or not you have aggressive prostate cancer, I think that we would adopt that, and then we would have the perfect test.
MARTIN: So, is your argument - if I can phrase it - that it is necessary to cast a wide net with the test in order to capture the people who most need to be tested? Is that your argument?
MARTIN: If you're just joining us, I'm Michel Martin, and you're listening to TELL ME MORE, from NPR News. I'm speaking with Dr. Compton Benjamin, a urologist, and Dr. Otis Brawley the chief medical officer and chief scientific officer at the American Cancer Society. And we're talking about those recommendations by a prominent and influential health task force that healthy men should not routinely receive those blood tests to screen for prostate cancer.
Well, Dr. Brawley, what about Dr. Benjamin's argument, though, that casting a wide net is necessary because that's the only way to capture the people who are most at risk, particularly African-Americans, who, as we - I think we can all agree - have a very fraught relationship with the medical establishment (unintelligible)? What about that?
BRAWLEY: And I encourage them to be reluctant. I think that - men are wise. You know, the task force statement last week they were not the first group of doctors who have looked at all the medical literature and come away with a statement saying there are questions here.
MARTIN: I know, Dr. Brawley, but I was asking you to focus particularly on African-American men who...
MARTIN: ...are 1.4 times as likely to have a new case of prostate cancer, two-and-a-half times as likely to die from prostate cancer. And I was talking about...
MARTIN: ...whether that wide net is necessary to capture (unintelligible)?
BRAWLEY: And I was to. This - now, see, let me tell you what the AUA says that should be done, and it does not happen. It says...
MARTIN: AUA is...
BRAWLEY: American Urological Association, the doctors who treat prostate cancer in the United States. Their printed statement is given the uncertainty that PSA testing results and more benefit than harm, a thoughtful and broad approach to PSA is critical. Patients need to be informed of the risk and benefits of testing before it is undertaken. That does not happen.
MARTIN: Dr. Benjamin?
BENJAMIN: I disagree. Now, I can't speak for everyone, but I know that in my relationship with my patients, the first thing I tell them is PSA is not a test for prostate cancer. It is a test of prostate health. Now, there are several things that can cause you to have an elevated PSA: a large prostate, an infection in your prostate, prostate cancer, or some kind of trauma to your prostate. We don't know what is causing your PSA to be elevated. Therefore, we need to do an additional test.
MARTIN: So is it your argument, in essence, that you need to hit people over the head with a hammer - for the sake of a phrase - just to get the people who most need to come in to come in. Is that essentially the argument?
BENJAMIN: It's very difficult. In the times that we have done screenings, we find that not only is the volume lower than we would expect, but the demographics is different than the population in the area. And I think that's because African-Americans either are not interested in having that test don't want to know, or aren't informed properly about the test and its benefits.
MARTIN: Okay, Dr. Brawley, what about that point? And you know you've already gotten tremendous heat for your stance on this.
MARTIN: It's similar to the conversation that we had a couple of years ago about breast cancer screening, where there was a similar argument that the studies didn't want the number of tests that were being done, that the results didn't warrant it. And so...
BRAWLEY: Well, I disagreed with the task force on breast cancer (unintelligible).
MARTIN: Exactly. That's one of the reasons it's interesting. You actually took the opposite position around breast cancer screenings.
BRAWLEY: Right, yeah.
MARTIN: You felt that routine mammography for women over a certain age is warranted (unintelligible).
BRAWLEY: Well, there are eight studies that show that screening women saves lives. The task force actually said that screening saves lives for women in their 40s. It just doesn't save enough of them to merit it. And that's the problem I had.
On this issue, we don't have the science. We have people saying don't tell men that the American Urological Association says that the benefits are not known to outweigh the harms. And then we have prostate screening being done at state fairs, in shopping malls. And the people who are doing this screening are saying don't tell men that there are questions as to whether this works. Then they won't get screened.
This is why I think black people are actually wise to be suspicious of what's going on in medicine. This is an example of medicine deceiving people. There is a legitimate use for PSA screening, but it's got to be limited and with informed decision-making.
MARTIN: Dr. Benjamin?
BENJAMIN: There are two major studies that were done, a European study and an American study. The American study said that there was no difference in mortality in patients who were screened and not screened. The European studies showed that there was a benefit in the patients that were screened.
I don't know how things have changed between the last time that the task force has made a recommendation and this time, because there's been no new information. Therefore, why now the big step saying that this is not warranted?
MARTIN: So I'm going to give Dr. Brawley the - I'm going to give you the last word. I gave Dr. Brawley the first word. So Dr. Brawley, a final thought from you, and I'm particularly interested in what those of your friends, family who consult you, what advice you're giving them on this question.
BRAWLEY: I tell them that on the issue of prostate screening, their guess is better than mine, because they have to live with the end result. And the truth be told is, scientifically, we do not know if screening saves lives. It may save lives. And the task force made a statement, because there's actually five studies of prostate screening.
All five of them demonstrate harms in prostate screening, one of them with huge biases. That European study showed that there was a benefit. It showed you had to treat 48 men in order to save one life.
MARTIN: And you don't think those odds warrant the level of investment that's now being made?
BRAWLEY: Well, again, five studies done, one showed benefit. The one that showed benefit had huge biases and problems, and with those huge biases and problems toward a finding that screening saved lives, it found that it just barely is beneficial: 48 men treated for one life saved.
MARTIN: Dr. Benjamin, giving you the final thought, what are you telling patients, friends, family?
BENJAMIN: I tell my patients exactly what I said in the beginning, that PSA is not a perfect test, but PSA is the best test we have. There is a lot of research going on right now looking for the perfect test for aggressive prostate cancer. It does not exist.
Until that time, if the patient has an elevated PSA, I think that we need to consider that that patient has prostate cancer and may benefit from having treatment of that prostate cancer.
MARTIN: But to the preventive task force recommendation that all healthy men, that healthy men should not routinely get PSA screening, what do you say?
BENJAMIN: I say that I myself will continue to be screened. I have a family history of prostate cancer. I am an African-American, and despite the risks of problems with the surgery - for instance, incontinence, leaking urine or impotence, not being able to get erections - I think that being there, to be for my kids as they grow up, is important to me.
And until they show me very conclusive evidence that there is no benefit to screening, I will continue to offer that, to talk to my patients and, with the relationship I've developed with my patients, come to a decision in terms of what they think is in their best interests.
MARTIN: Two views. Dr. Compton Benjamin is a urologist at the George Washington Medical Faculty Associates. He's an assistant professor at the George Washington School of Medicine and Health Sciences. Dr. Otis Brawley is the chief medical officer at the American Cancer Society. He's also a professor of hematology, oncology, medicine and epidemiology at Emory University, and they were both kind enough to join us in our Washington, D.C., studios. Gentlemen, thank you both so much.
BENJAMIN: Thank you.
BRAWLEY: Thank you.
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