As regular HealthBeat readers know, I’ve been writing about the risks of PSA testing for early-stage prostate cancer since I launched this blog in 2007.
The American Cancer Society does not support routine PSA testing for prostate cancer. Testing often leads to unnecessary treatment which, in turn, leads to life-changing side effects—namely incontinence and impotence. Moreover, early detection does not guarantee a cure. See these posts on HeathBeat: here and here. Finally, see this very informative NYT story that I posted about in 2008.
Nevertheless, The New York Daily News has once again launched a campaign urging men to take advantage of FREE PSA testing. (Of course the treatment that follows won’t be free, but that’s another story.)
Over at HealthNews ReviewBlog, Gary Schwitzer, who does his best to keep the media honest, offers an excellent critique of the Daily News campaign. His post begins below:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Headlines every day in the New York Daily News are luring men in as part of a mass prostate cancer screening campaign which the American Cancer Society not only does not endorse – its chief medical officer recommends against. Yet the paper brags that it is beginning its second decade of this non-evidence-based campaign. Sample headlines:
• Doctors urge New York men to take advantage of free, city-wide PSA testing
• What you don't know can kill you. Get a FREE prostate cancer test. It can save your life
• Bring dad in for FREE prostate cancer test across the city on Father's Dayand
• Don't skip the PSA test! My prostate cancer is treatable because simple test caught it early (written by a Daily News staffer).
Meantime, as I wrote one year ago when the Daily News promoted this campaign:
Either the paper doesn't realize or doesn't care that:
* The American Cancer Society does not support routine testing for prostate cancer at this time and specifically recommends AGAINST such mass screenings.
* The US Preventive Services Task Force and the American Academy of Family Physicians state that "Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years."
* No major group – except urologists – recommends starting screening as early as this newspaper does – starting at age 40. And that urology group's thinking is the source of major controversy.
That's a huge public responsibility for a newspaper to take on – especially when it conflicts with medical evidence.
Before being screened, what did the newspaper inform men about the tradeoff of harms and benefits? On the American Cancer Society website, its president, Dr. Otis Brawley says:
"There are some proven harms associated with screening. Screening, for example, leads to unnecessary treatment in some men who are diagnosed with localized disease.
It is difficult to comprehend, but there are prostate cancers that are confined to the prostate and never destined to metastasize (spread to other parts of the body). Screening diagnoses a large number of men who would never be bothered by the disease. In one clinical trial, more than 12% of average risk men were diagnosed through screening over 7 years. This group of men is estimated to have a lifetime risk of death of less than 4%. This study suggests that 2 out every 3 men in this study did not need to be diagnosed nor treated. While this study suggests that the proportion of men in the overall population who are diagnosed with cancers that do not need therapy is as high as 67% of men with localized disease, others estimate it to be as low as 30%. We have very poor ways of predicting who needs treatment because their prostate cancer might kill them, and who does not need therapy because their tumor is of no threat to them."
It's not just a simple blood test, as it is so often promoted. That's why Dr. Brawley says:
"Many health care provider organizations and many well-meaning community groups encourage prostate cancer screening and offer mass screening at health fairs and other activities. The American Cancer Society is concerned that so many do not understand that the benefits of screening are still undetermined. The ACS recommends against such mass screening activities because one cannot be assured that the patient has the opportunity to hear a balanced explanation of screening in an environment in which he can feel comfortable to ask questions and make an informed decision."
Even more to the point of the newspaper's promotion and advertising of this mass screening, Brawley wrote in an editorial in the Journal of the National Cancer Institute:
"I heard a radio commercial that brings perspective to the issue. A local celebrity was promoting prostate cancer awareness. He said, "Prostate cancer is 100% curable when caught early." He encouraged all men to get screened and announced that a van was touring the area offering screening in supermarket parking lots. This was a community service project sponsored by the radio station, the supermarket chain, and a radiation oncology practice.
A commercial like this plays to our fears and prejudices. …
Prostate cancer screening has resulted in substantial overdiagnosis and in unnecessary treatment. It may have saved relatively few lives. … The benefits of prostate cancer screening are still open to question. This means that informed or shared decision making should be done using the data now available before screening is performed. Some of the confusion of prostate cancer screening can be avoided if we all clearly label what we know, as what we know; what we do not know, as what we do not know; and what we believe, as what we believe. Of course, one must not confuse what is believed with what is known to do this."
If I hadn’t had a psa test, I’d be dead. You have no clue what you are talking about. It is very easy to track the protein level increases without invasion, and at the same time screen for rapid PC cancer. Mine was rapid, and without the screening would have escaped the margins and then the rest would have been history.
The number of lives that have been saved is in the hundreds of thousands.
Despite the headline in the News, the item does seem to target African-American men who do have a higher incidence of prostate cancer. Population screening of this group is of course still not the way forward, but the item could usefully have helped to raise awareness among these men of risk factors and symptoms.
Marc, Hoyt
Marc: Here’s the problem: we don’t have clear evidence that any of our treatments for prostate cancer work to reduce mortalities– or even extend life by one day.
Some treatments may help some patients — but there’s no evidence. (Because the disease usually moves so slowly, we need a study that follows patients for many years. One such study has been begun but is not yet completed.)
Meanwhile, many patients are hurt by treatments for early-stage prostate cancerin cases where the disease would never would have hurt them.(They would have died of something else before experiencing symptoms.)
Doctors just don’t know what to tell African-American men, and others at higher risk (because a relative died of prostate cancer, for instance.)
Should they be tested? Maybe. But then what? IF they are able to accept “watchful waiting”– –keeping an eye on PSA levels–without feeling that they must do something, that’s probably the best strategy.
But a great many men can’t do that. They feel their is a sword hanging over their head. So they suffer great anxiety, in most cases, for no reason.
The research does show that in terms of mortalities, men who opt for watchful waiting do about as well as men who are treated. . .
The ACS, the NCS and everyone (except the urologists’ society) says that men should be told about the downside of being tested, and the uncertainty about effectivenss of treatments beforoe being tested.
There is so much uncertaintly that all one can do is give the patient the informaiton and let him make the decision.
But the NY Daily News isn’t doing that. And putting peopole on red alert about a disease when we don’t have a cure or even a treatment that is clearly effective is really not doing them any favors.
Hoyt– Please see the NYT piece I linked to as well as my posts and the medical journal articles that I link to in those posts. .
I’m very glad you’re well, and it’s quite possible that treatment helped you.
AS you know, fast-moving prostate cancer is unusual.
But there is no evidnece that “hundreds of thousands” have been helped by treatment.
Meanwhile there is evidence that tends of thousands have been hurt by treatments and that the vast majority of men diagnosed with prostate cancer would never have experienced symptoms.
Btw, assertions such as “You have no clue what you’re talking about” only undermine your credibility–especially because I cite so much evidence from peer-reviewed medical journals when writing about PSA testing.
To make an argument, you need to cite medical evidence. On HealthBeat, we try to avoid personal attacks.
My local newspaper ran a similar type of article six or eight months ago. A local preacher was featured in a story about how he used his pulpit to urge men to get screened for prostate cancer.
I got eviscerated by some local bloggers when I explained the very things Maggie does in this and previous articles. But fortunately, there were enough folks who were willing to read what I wrote objectively. Continuing education against bad medical information is a big part of why I blog.
My father had an elevated PSA twice. Twice he had to undergo painful mapping of his prostate. On the last occassion, the urologist kept getting paged to ICU for a critical patient who was going downhill. Dad had to be fasting for this procedure; he was diabetic. Then, the secretary allowed a pregnant patient to take a room ahead of my dad so she could get to her baby shower on time. It was well after noon before the biopsy was finally done.
Dad’s blood sugar dropped like a stone, and it was all my mother could do to get him to eat.
I told Dad not to get another PSA; it just wasn’t worth the risks to identify a disease that I knew would not be his cause of death (he also had major CAD).
It’s like anything else in medicine: you HAVE to look at the risks vs the benefits.
24000 men die per year of PC. Those are the facts. A psa test is noninvasive and provides an alert. Yes slow growth PC can be a watch state, but when a Psa goes from 1 to 4.4 to 5.8 in 12 months, you don’t have to be a rocket scientist to know that you should get a biopsy. I had a large tumor so the reference that you do not know what your talking about is a reference to the many men who have done the opposite of your conclusion.
Based on two recent major clinical trials, the practice of routinely screening men with the PSA test has at best a small effect on deaths from prostate cancer, according to a review, published in CA: A Cancer Journal for Clinicians.
The studies, which came out earlier this year in The New England Journal of Medicine, appear to bolster the positions of the American Cancer Society (ACS) and other major medical groups, which do not recommend routine PSA screening for symptom-free men at average risk of developing prostate cancer.
Prostate-specific antigen (PSA), is a protein produced by the prostate gland, blood levels of which generally rise when a prostate tumor is present, although not cancer specific. PSA blood tests can catch the cancer in its early stages.
But while use of the test has led to more prostate cancer diagnoses, it has done little to nothing to actually cut death rates from the disease, according to the researchers on the review, led by Dr. Otis W. Brawley of the ACS.
In one of the recent trials, U.S. researchers found that among more than 38,000 men between the ages of 55 and 70, annual PSA screening was no more effective than less-frequent screening at cutting prostate cancer death rates.
The second study, of 182,000 European men, found that PSA screening every few years was associated with only a modest reduction in death risk.
The central problem with prostate cancer screening is that most prostate tumors are slow-growing and would not be deadly even without treatment. So screening can lead to unnecessary treatment of cancers that would never had been life-threatening.
Because prostate cancer treatments, such as surgery and radiation, can have side effects — incontinence and erectile dysfunction, for instance — it is possible to do many men more harm than good by treating small tumors.
Researchers are continuing to study ways to refine prostate cancer screening, Brawley and his colleagues point out. That includes measuring “biomarkers” other than PSA that may be able to not only signal the presence of tumors, but also indicate whether they are aggressive and require immediate treatment.
Until then, the researchers say, men should talk with their doctors about whether PSA screening is a good idea. A man’s personal risk factors for the disease — including his family history of prostate cancer — are key in that decision, according to Brawley’s team.
The ACS recommends that most men discuss the possibility of PSA screening with their doctors starting at age 50. Men who are at relatively higher risk — including those with a brother or father who developed prostate cancer before the age of 65 — can have that talk after age 40. PSA screening is not generally recommended for men age 75 and older.
SOURCE: CA: A Cancer Journal for Clinicians, July/August 2009
This is an excellent article from ACS’ Brawley does a good job of summarizing and applying logic to the confusing and sometimes contradictory opinions on this topic. Prostate treatment has become such a huge industry with immense cash flow. It feeds on some of our worst fears.
http://jnci.oxfordjournals.org/cgi/content/full/djp310
You’d have to treat 48 prostate cancers (typically with radical prostatectomy) to prevent one death from prostate cancer, and the morbidity (big time erectile dysfunction, urinary incontinence, pain and suffering) is severe.
http://www.medscape.com/viewarticle/707771
Never too much of a good thing is there?
Hoyt,
Your story, while compelling, is what is known as anecdoctal evidence. It is one personal story vs the many formally written and researched studies and trials that show that early PSA testing is more costly, leads to over treatment, and creates tremendous anxieties for patients and their families.
I happy for you that your story resulted in a good diagnosis and good outcome. But your situation is the exception not the rule in that for most men, early PSA testing is worthless.
My own story, while anecdotal, is supported by the scientific evidence; when my father’s PSA was elevated for the second time, he thought for sure he had prostate cancer. He concealed this information from me (I lived in California at the time, he lived in Maryland) until after he got the results of the PSA mapping back. The stress and frustration were clear in his voice when he told me what happened, and prompted me to move back to the East Coast so I could be closer by to support my parents. That’s when I explained to him the true value of PSA testing (or rather, the lack therof; Dad was 73 at the time) and urged him not to get another one (he didn’t).
Personal stories like ours are all well and good, but the public needs reliable information to make truly informed decisions. That information comes from controlled studies. And the information that those studies has provided for us tell us that early PSA’s are useless.
As health care professionals, we do our patients a disservice when we educate based on emotional experiences in defiance of the scientific evidence.
Thanks for this Maggie. Unfortunately the comments make clear our failure as a profession to properly educate our patients about screening test, and the failure of the “early detection, early cure” strategy.
It certainly is an uncomfortable feeling to know how many men will die from prostate cancer, and to have something we could use as a screening test and not use it. Unfortunately, the screening test we have is not an effective screening test.
If all the money spent on unnecessary treatment for elevated PSAs were spent on research for a better screening test we might actually have something useful. I see the PSA exclusively as a test for treatment effectiveness and for resurgence of an already diagnosed cancer.
Per the reference to the father who was 73, obviously the validity of a test can be debated at that age. When 28,000 men die from prostate cancer, and the death rate has been shown factually to be statistically dropping, it is hard to argue about spending 20$-60$ for a PSA test. Obviously if scores emerge in a low 2 or 3 category, then the watch strategy makes perfect sense. When the psa tests spike at a rapid rate, then that requires a totally different strategy where obviously you need to monitor it and take action.
As in all medicine, testing and treatments can be abused. The parallel of course is breat cancer with the 1000’s of false reading, yet how many women have been saved?
As in all of these cases, there is a balance. Mine happens to be a scenario where it clearly saved my life. At 55, it is rather difficult to play Russian roulette where you disregard the risks at the expense of your family. My biopsy confirmed that I was at a very high risk with a gleason of 8-10.
My point is simple: PSA tests have saved countless men, and yes there are those who could have survived without surgery, radiation etc.
The research studies may some day show a proper balance. As noted below:
There has been a gradual but steady decline in prostate cancer mortality in the U.S. of approximately 30%. This trend began fairly soon after the introduction of PSA testing, there is
evidence from statistical modeling studies that PSA testing has played a role. Screening with PSA is responsible for a substantial shift towards detection of prostate cancer at earlier
stages. Moreover, recent evidence from both a randomized trial in Sweden and a wellcontrolled
cohort study in the U.S. indicate that active treatment of clinically localized prostate
cancer may reduce prostate cancer specific mortality.24, 25 Data from observational studies in the
US and Austria also suggest an association between PSA screening and decreased prostate cancer specific mortality.26, 27
Sharon M.D., Greg, Hoyt, Ed, Pancea
Sharon M.D.–
I totally agree about how the PSA test should be used.
And you’re right, all of that money could be invested in finding a better test. We need a test that distinguishes between prostate cancers that will advance and those that won’t.
We also need more research comparing treatments to see whether any existing treatments–or new treatments– will actually reduce mortalities, or at least, lenghten lives.
Greg–
Thank you very much for the references to medical evidence.
I hope that anyone reading this post, and trying to figure out what to think, will go to those medical journal articles.
I am not an M.D. Men need to read the medical evidence (or ask their doctors to tell them about the medical evidence) before making their decisons.
But they definitely shouldn’t make their decisions based on an article they read in the newspaper (or a post they read in the blogosphere. I try to provide links to medical journals that offer information based on medical evidence.If a reader has a serious concern, I hope he will click on the links–if only to find questions for his doctor..)
Ed: Nothing succeeds like excess!
Pancea–
Thanks for both of your comments.
A preacher using his pulpit to aruge for PSA testing. . .
I’m afraid this it typical
Very well-meaning people who know nothing about the medical evidence campaign for PSA testing. To them, it seems very simple.
But many men suffer great harm as a result.
I, too, am glad that Hoyt’s story ended so well.
But it is, as you say, just one story among millions.
We have no idea why he survived.
We do know that often early detection does not save men from death via prostate cancer.
And we do know that the PSa test is, as you say, “all but useless.”
This is why the ACS and the NCA no longer recommend it.
Your Dad was lucky that you were able to spare him furtherm needless suffering.
Hoyt-
Please see Pancea’s comment just below yours.
We’re very glad that things worked out so well for you. But your recovery has far more to do with luck (and perhaps lucky genes) than the efficacy of PSA testing.
It just frustrates me that the media will publish medical information in such a one-sided fashion. People buy into this and are fear-driven to take action.
Mark B.–
Yes, it is frustrating.
Though, as Schwitzer points out, often people in the media (and very likely those at the Daily News) truly believe what they are reporting.
They have been misled by so-called “experts” who profit from unnecessary treatments.
Ideally, reporters would be more skeptical– they would question some of the good news that they hear from experts, and dig further.
(I have found is that all you have to do is Google the claim (for example “PSA tests save lives”, and “critics say.” That will give you the other side of the story. If it sounds persuasive, you pursue it–look up the medical jouranl articles, etc..)
Hoyt–
Researchers have looked into the decline in prosate cancer mortality and have not been able to link it to PSA testing.
My guess is that some men have been saved by PSA testing–but we have no medical evidence that this is true.
We do have medical evidence that a great many men have been harmed by treatment for early-stage prostate cancer.
We have no way of knowing if, in any individual case, their prostate cancer would have advanced. But we do know that the vast majority would never have experienced symptoms.
That said, if my husband’s PSA score was rising rapidly, along with his Gleeason score, I would think that he probably should do something.
Put it this way: at that point, we have nothing to lose. We might as well gamble on a treatment, even though there is no medical evidence that it will help. There is also no medical evidenced that it won’t help. (There is at least one long-term trial going on that may answer this question, but it won’t be completed for another few years.)
Once again, I’m very glad that this worked out for you. And I totally understand why you would go for treatment– you had a fast-growing cancer.
But yours is a rare case. I’m directing my comments to the vast majority of patients who are diagnosed with early stage prostate cancer . . if they just watch and wait, normally it will not progress.
In general, people who have been treated for cancer that was discovered via screeing are reluctant to entertain the possibility that they may not have needed treatment in the first place (like Hoyt). But here’s an excellent article by a prostate cancer “survivor” who wonders whether he even needed treatment. http://www.msnbc.msn.com/id/35874966/ns/health-mens_health/
A pathologist who examined the tissue that was cut out of his body said that it may have started to bother him in “4 or 5 years”. He could have spent those years intact and fully functioning as a man. Yet because he followed medical advice he may never regain potency. And he wasn’t that old (57).
The man who discovered PSA now believes that this has led to a “profit-driven public health disaster”. I grieve for the misery that has been visited on unsuspecting men who were only doing what they thought was best.
KittyKitty–
Thanks for the link. And yes, many men become victims of over-treatment for prostate cancer.
Thanks for the link–
This is an interesting spin on it. Regardless of whether or not PSA testing over diagnoses people who would otherwise be fine, it would be hard to say given how cancer can suddenly spread.
I’d rather my husband be screen and know if there is a problem and then see what courses of action should be taken than not worry about it.
Alice–
What you don’t seem to un derstand is that we have no hard medical evidence that any of the treatments for early-stage prostate cancer work to save lives, or even to prolong life by one month.
We do have evidence that many men who undergo treatment didn’t need it (the cancer never would have caught up with them) and as a result of the treatment, they become incontinent and/or impotent.
I heard a similar story about this and breast cancer. I think confusion happens when rules get in the way of common sense.
This is what I know from the other side of prostate cancer.
earlier treatment, better recovery
1. The more you know, the better the recovery
2. Seeing a specialist before surgery can improve chances of a return to presurgery sexual activity
3. There is a finite period following surgery in which to prevent long lasting ED
the MD listed above is in NY metro area and has had success with this type of protocol with my other half.. Get in touch with him to see if you are a candidate for his treatments.