Jose Luis Magana/AP
Terry Dyroff, at home in Silver Spring, Md., got a PSA blood test that led to a prostate biopsy. The biopsy found no cancer, but it gave him a life-threatening infection.
Jose Luis Magana/AP
There they go again — those 17 federally appointed experts at the U.S. Preventive Services Task Force are telling American doctors and patients to stop routinely doing lifesaving tests.
Or at least that's the way some people look at the task force's latest guidelines on prostate cancer screening, which say doctors should stop doing routine PSA tests on men of any age. (The task force earlier recommended an end to testing of men over 75.) You can find the screening guideline in that current issue of Annals of Internal Medicine, along with editorials for and against it.
The American Urological Association pronounced itself "outraged" at the task force edict.
"It really is too extreme for them to say that all PSA testing should stop," fumes Dr. William Catalona, a Northwestern University urologist and PSA testing pioneer. "If all PSA screening were to stop, there would be thousands of men who would unnecessarily suffer and die from prostate cancer."
Catalona insists the evidence suggests routine PSA screening prevents as many as 40 percent of prostate cancer deaths by catching the disease when it's early and curable.
No way, says Dr. Michael LeFevre, a task force member who is professor of family practice at the University of Missouri.
"We think the benefit is very small," LeFevre told Shots. "Our range is between zero and one prostate cancer death avoided for every thousand men screened." By comparison, he says, the lifesaving benefit from colorectal cancer screening is two to 10 times higher.
LeFevre doesn't deny PSA screening saves lives. It's just that the benefit is much smaller than screening advocates think, he says. His best case: Widespread PSA testing might avoid between 1,400 and 2,800 prostate cancer deaths among 28,000 US men who now die of the disease. That's 5 to 10 percent.
"I don't want to take lightly any one of those lives," he says. "And if prostate cancer screening was harmless and nobody suffered the consequences on the opposite side, then I'd say, 'Well, why not?' But unfortunately, that's not the case."
The task force says up to 20 percent of men screened every year for 10 years will get a result that sends them to the biopsy suite. When cancer is found, nearly 90 percent will have surgery, radiation or hormone therapy, and up to one-third will end up with urinary incontinence, impotence or bowel problems.
Death from prostate cancer is a worse harm, for sure. But the task force says most of the men treated for cancer found through PSA screening would never have had a problem with the disease if it hadn't been found.
"A goodly proportion of men who have localized prostate cancer actually have a disease that will never kill them if left alone," says Dr. Otis Brawley, the American Cancer Society's chief medical officer. "More than a million men were needlessly cured of their prostate cancer over the last 20 years."
Brawley says this notion — experts call it "overdiagnosis" — is hard for most people to grasp, including cancer doctors (or perhaps especially cancer doctors). "What the Preventive Services Task Force is suggesting is contrary to all our prejudices," he told Shots. "We've all been taught that the way to deal with cancer is to find it early and cut it out."
He especially hopes the new guidelines will put a stop to mass PSA screening by mobile vans at shopping malls and hospital-sponsored "health fairs."
Brawley has been beating that drum since 1997, when an especially candid hospital marketing director bragged to him about the financial advantages of his institution's free PSA screening sessions. He recounts the story in his recently published book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.
"The marketing guy was really proud of his prostate-cancer-screening business plan," Brawley told Shots. "If they screened 1,000 men at the mall ... they got 135 guys coming in [to the hospital's clinics] to figure out why they had an abnormal test. And they would end up collecting an average of $3,000 per guy off of that."
From there, many biopsies would reveal prostate cancer, and nearly all of them would have surgery or radiation, he says. The ones who got radiation, the marketer told Brawley, "reimbursed at almost $80,000 a guy."
"I asked him, 'How many lives will you save if you screen a thousand guys?' " Brawley recalls. "And he took his glasses off and looked at me as if I was a fool and said, 'Don't you know, nobody knows if this stuff saves lives? I can't give you an estimate on that.' "
Brawley says some PSA screening fairs are sponsored by the makers of diapers for incontinent adults, apparently because they know many men with abnormal PSAs will eventually suffer treatment-related urinary problems. "I don't know if screening saves lives, but I sure know it sells diapers."
A Matter Of Semantics?
Brawley is himself an expert in prostate cancer treatment. And as opposed as he is to indiscriminate mass screening, he says he's not against PSA testing if doctors and patients go into it with open eyes, after a frank discussion of potential harms and benefits.
But while he thinks the Preventive Services Task Force "got it right," he says it needs to do a better job of explaining itself. As in the mammography screening controversy of 2009, the task force's analytical language leaves it open to the charge that it's unsympathetic to men's prostate cancer fears and diagnostic dilemma — coldhearted even.
"I wish the task force's wording were a little bit more user-friendly," Brawley says.
Instead of saying that doctors should stop doing PSA "routinely," he says, maybe it should have said they shouldn't do them "automatically."
That leaves the door open to a doctor-patient discussion about the pros and cons. And that's exactly what the task force says it wants to do.