Times are changing. Americans are beginning to acknowledge that “early detection” is not the absolute answer to cancer. And many are recognizing that what seems a simple diagnostic test can carry more risks than benefits.
Tuesday, the New York Times ran an Op-ed by Richard J. Ablin, the man who invented the prostate-specific-antigen (PSA) test which is widely used to detect signs of early-stage prostate cancer. Ablin, who is now a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research, reveals that “in approving the procedure, the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 percent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.
“Still, 3.8 percent is a small number,” he observes. “Nevertheless, especially in the early days of screening, men with a reading over four nanograms per milliliter were sent for painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always pushed into surgery, intensive radiation or other damaging treatments.”
Prostate cancer is a tricky disease because the cancer grows so slowly. A great many men who are diagnosed with prostate cancer will die of something else—long before the symptoms of the cancer catch up with them. As Ablin points out , because PSA testing is pervasive, “American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it.”
This is why, in many cases, doctors recommend “watchful waiting.” Keep an eye on the cancer, but don’t treat it unless there is evidence that it is growing.
30 Million Men, $30 Billion Dollars –Little or No Reduction in Mortalities?
Ablin has been frustrated by the widespread use of the test. Each year, he notes, some 30 million men undergo PSA testing, at a cost of $30 Billion. Yet “the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. “
Moreover, the benefits of treatment are uncertain. Last year, The New England Journal of Medicine published results from the two largest studies of the screening procedure, one in Europe and one in the United States. The results from the American study that over a period of 7 to 10 years, screening did not reduce the death rate in men 55 and over. The European study showed a small decline in death rates, but also found that 48 men would need to be treated to save one life. “That’s 47 men who, in all likelihood, can no longer function sexually or stay out of the bathroom for long,” Albin adds, referring to the fact that treatments can lead to long-term incontinence and/or impotence.
He acknowledges that “Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer. But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”
Indeed, “drug companies continue peddling the tests and advocacy groups push ‘prostate cancer awarenes’” by encouraging men to get screened. Shamefully, the American Urological Association still recommends screening. But slowly others in the medical community are responding to the research. The American Cancer Society now urges more caution in using the test and the American College of Preventive Medicine has concluded that there was insufficient evidence to recommend routine screening.
Many Reluctant to Hear the News
I’ve been writing about PSA testing and prostate cancer since I began this blog in August of 2007: “Screening for Prostate Cancer: Before Medicare Pays, Patients Need to Know more About Risks” ; “What Rudy—And Most Americans Don’t Understand About Prostate Cancer” ; “How the Mainstream Media Hypes HealthCare”. In each case, I was trying to warn that patients who are tested and treated may suffer life-changing side effects that outweigh the uncertain benefits of early detection.
Inevitably, the posts drew some irate responses from readers who were sure that they, their husband, or their uncle’s life had been saved by PSA testing. The truth is that once a patient is treated for early-stage prostate cancer there is usually no way of knowing whether he would have been one of the very few who might have died of the disease if he had not been treated– or one of the many who would have died of something else, long before the diseases caused problems. If they hadn’t been tested, those men would never have known that they had prostate cancer. But once treated, few want to admit that the treatment might have been unnecessary, particularly if they wind up coping with life-changing side-effects. Human beings will do anything to avoid regret.
At this point, I believe the answer is to make sure that patients are s given full information about the risks and benefits of PSA testing and treatments for early-stage prostate cancer before making a decision as to whether they want the test. I have written about “shared decision-making” programs that help men decide whether they to go ahead with the test —and whether they want treatment if they are diagnosed here.
Shared decision-making also can protect a doctor against the possibility of a lawsuit a patient who decides against the test later develops prostate cancer. In the state of Washington, a relatively new law makes it extremely difficult for a patient to sue for malpractice if he has gone through the “shared decision- making” protocol before deciding on elective surgery for a variety of conditions.. Other states are considering passing similar laws.
The Media Begins to Help Educate: More Care Is Not Always Better
Ablin has been trying to get the word out for some time. Yet it is only now that the New York Times ran his very candid Op-ed. I doubt that the Times would have accepted it two years ago.
But now the health care reform movement has opened up the discussion of over-treatment and over-testing. The mainstream media is beginning to explain that diagnostic testing can be a double-edged sword. (See Naomi’s HealthBeat post on mammograms here). At best, very good tests will detect a disease that can be cured. At worst, an epidemic of testing leads to diagnosis of diseases that never would have hurt the patient. Too often, diagnosis of a “pseudo-disease” leads to unnecessary surgeries and radiation.
Patients are hurt—needlessly. And health care dollars are squandered. As a HealthBeat reader reminded me in an e-mail today: “The growth of PSA use led to the explosion in radical prostatectomies which is the procedure which made the business case for robotic surgery , and is now the underlying reason that two incredibly expensive proton beam accelerators are in planning or being built in the Chicago area. A tangled web and one reason our healthcare costs are what they are and still growing.”