Treatments

Doctors' Orders: Keep Men Involved in PSA Decision

Terry Dyroff of Silver Spring, Md., had a PSA result that led to a biopsy, which found no cancer. But the biopsy gave Dyroff a life-threatening infection. A U.S. task force recently proposed junking routine PSA tests, arguing they offer little benefit. But a commentary in the New England Journal of Medicine says the decision should be up to patients. i i

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Terry Dyroff of Silver Spring, Md., had a PSA result that led to a biopsy, which found no cancer. But the biopsy gave Dyroff a life-threatening infection. A U.S. task force recently proposed junking routine PSA tests, arguing they offer little benefit. But a commentary in the New England Journal of Medicine says the decision should be up to patients.

Jose Luis Magana/AP
Terry Dyroff of Silver Spring, Md., had a PSA result that led to a biopsy, which found no cancer. But the biopsy gave Dyroff a life-threatening infection. A U.S. task force recently proposed junking routine PSA tests, arguing they offer little benefit. But a commentary in the New England Journal of Medicine says the decision should be up to patients.

Terry Dyroff of Silver Spring, Md., had a PSA result that led to a biopsy, which found no cancer. But the biopsy gave Dyroff a life-threatening infection. A U.S. task force recently proposed junking routine PSA tests, arguing they offer little benefit. But a commentary in the New England Journal of Medicine says the decision should be up to patients.

Jose Luis Magana/AP

Hey guys, feeling confused about the fuss over PSA screening for prostate cancer?

Listen up. A couple of docs who ponder such medical dilemmas say there's a middle ground between business-as-usual and throwing PSA tests out altogether.

You may recall the U.S. Preventive Services Task Force kicked up a ruckus earlier this month when it proposed junking routine PSA tests. If you're male and middle-aged or beyond, your doctor has probably ordered that blood test (maybe without asking first) to see if your prostate might be harboring a malignant lump.

The influential task force says PSA tests cause too much mischief (false alarms, needless biopsies, unnecessary surgery and radiation, lifelong side-effects like impotence and incontinence) for not much benefit (little or no reduction in overall prostate cancer deaths).

But that's way too black-and-white for a situation where there's so much debate among the experts, say Drs. Mary McNaughton-Collins and Michael J. Barry. He's president of the Foundation for Informed Medical Decision-Making; she's a Harvard physician who's thought deeply about the prostate cancer conundrum.

"The way to address uncertainty is to allow patients the central position in decision-making," the duo write in an online commentary in New England Journal of Medicine

Sounds uncontroversial, but in fact McNaughton-Collins and Barry point out that the task force's proposal actually "removes the patient from the equation" by classifying it as a "grade D recommendation."

In the task force's arcane nomenclature, that means it thinks PSA screening has no net benefit, or that the harms outweigh any benefits, and doctors should be discouraged from offering PSA tests. The strong implication is that patients don't even need to be in the picture.

Wrong, say McNaughton-Collins and Barry. "We do not believe that anyone but the patient should decide whether the small and uncertain benefits of PSA screening are worth it," they write.

That puts a burden on you, Mr. Patient, as well as your doctor. You've got to get into the weeds, at least a bit, and be as clear as you can about the issues and the evidence.

An accompanying NEJM analysis by Dr. Richard Hoffman of the University of New Mexico nicely lays out those issues. Some sample factoids:

— Nine out of 10 prostate cancers in this country are detected through PSA screening.

— A 2009 European study involving more than 182,000 men found only a slight reduction in prostate cancer deaths among those who had regular PSA screening, and that was seen only among men between 55 and 69.

— A U.S. study of 77,000 men, also published in 2009, found no reduction in death (from prostate cancer or any cause) among those who had regular PSA screening.

— Most men who have "abnormal" PSA readings (usually considered above 4.0) do not have prostate cancer, but many of them will have biopsies to look for it, and most of those biopsies will be normal.

— A normal PSA level is no guarantee that a man doesn't have prostate cancer — although it may be a cancer that would never have been detected. In the large Prostate Cancer Prevention Trial, about one in seven men with normal PSA readings turned out to have cancer when their prostates were biopsied.

— Just because doctors find prostate cancer doesn't mean it's going to kill you. Among men who didn't have treatment, 8 to 26 percent ultimately died of prostate cancer, while other causes killed nearly 60 percent. The PSA test doesn't tell you who has a dangerous kind and who doesn't.

Some men pondering those kinds of facts will want to get a PSA reading anyway and then think about what to do. Others will say let's not do it if the results of the test are so prone to mis- or over-interpretation.

Wherever you (or your husband) comes out on that question, McNaughton-Collins and Barry say the current debate should put a stop to the common practice of doctors ordering PSA tests without talking to their patients first. Or not discussing beforehand what the patient thinks he might do if the PSA level is high.

"We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve," Barry and McNaughton-Collins say. "That's the way to help put the controversy to rest – one man at a time."

The task force, a government-convened panel of outside experts, is collecting public comments on its scheduled to announce its final recommendation on PSA screening until Nov. 8.

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