Jan 03

An influential government panel’s recommendation that healthy guys not get tested for prostate cancer — because that knowledge can do more harm than good — leaves some male patients and their doctors in a rather uncomfortable situation.

The U.S. Preventive Services Task Force panel, a kind of Supreme Court for judging what works in medicine and what doesn’t, is expected to issue a report on Tuesday recommending against routine screening with the so-called PSA blood test, suggesting that there is moderate to high certainty that harm from the test outweighs the benefits, largely because of a high rate of false positives.

For nearly a decade, medicine has been debating the value of the PSA test. In 2009, two large studies showed that routine PSA screening did little to prevent prostate cancer deaths.

But without any screening to replace it, even while men continue to be drilled with prostate cancer awareness campaigns, the new guidelines may not change practice.

San Diego internist Dr. Mark Adrian sees the confusion in his male patients and feels a little of it himself.

“I get where the studies are coming from,” he said. “You get a PSA in that mid-range and you don’t really know what to do with that. ‘Gosh, do we send him to urology’” for a biopsy? “I don’t think that is the right approach either.”

Large statistical studies gauging utility of the test may be powerful, Dr. Troy Hampton, a primary care physician affiliated with the Fairfield Medical Center in Lancaster, Ohio, said. But for most men, only one data point matters: themselves. Without any test to replace PSA, they are going to want it.

Approximately 240,890 men in the United States are expected to be diagnosed with prostate cancer in 2011, according to the American Cancer Society. About 33,720 of them will die. Behind lung cancer, it’s the most deadly form of cancer in men.

Yet, PSA test results lead many men to have unnecessary biopsies, treatments and surgeries that don’t save their lives, but do lead to side effects like incontinence, impotence, and worry when most prostate cancers are so slow growing most men die of some other cause long before the prostate cancer affects them.

But the test, like other cancer screening tests, has become entrenched.

In 2009, when the same panel recommended that most women under 50 did not need to get mammograms, and that women over 50 need them only every two years, and that routine mammogram screening for breast cancer was pointless for women over 75, many women reacted with fear and confusion.

Hampton doesn’t even expect his male patients to bring it up. “If anybody did make any comment, it would be ‘I would still like to get it.’ They still want that service.”

But then what? If a test should come back elevated, he said, the subtleties of explaining how prostate cancer usually has little or no impact on a man is lost.

“As soon as you say cancer, the conversation stops and everything goes into slow motion,” he said. Men want the cancer gone and they want it gone now and that means biopsies and treatment.

“That is why we are not ready for the test, in my opinion,” Ruth Etzioni, an investigator and biostatistician with the Fred Hutchinson Cancer Research Center in Seattle explained.

People need to learn that it is possible to live completely healthy, normal lives even if cancer is present, depending on the cancer type, she said.

Yet she knows some fellow investigators, very sophisticated about disease and statistics, who say they do not want the PSA test because they could not live knowing that they carried cancer cells in their bodies. They’d want it treated.

A combination of cancer fear and financial incentives have made prostate cancer big business.

At a Quest Diagnostics lab in San Diego, for example, a routine screening costs $152 including the blood draw (many labs cost less). Millions of men have the test every year and Medicare pays 100 percent of the cost for its recipients.

Etzioni says the test is not completely useless and feel the amount of harm caused by the screening has been slightly exaggerated. Prostate cancer deaths rates have dropped and she credits a combination of PSA screening and better treatment for aggressive forms of the disease. But she agrees the test is overused and that many men have been over-treated.

Nevertheless, it’s too late to put prostate cancer back in the bag, Adrian said. “I think male patients will be in more discomfort not knowing,” he said. “I think you should still do it.”



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