In a recent article in the New York Times, Jane Brody argues that older adults should be wary of cancer screening because it can lead to false positives and needlessly invasive testing. She also cites a draft recommendation from the U.S. Preventive Services Task Force, which concludes that the benefits of screening for prostate cancer just barely outweigh the risks and which also recommends no PSA screening for men aged 70 and older. (“When to Skip the Medical Tests” July 18, 2017, New York Edition, page D7, retitled online “With Cancer Screening, Better Safe than Sorry?” )
I’m not a medical doctor, much less a specialist in prostate cancer, and I’ve never even played one on TV. But having been diagnosed with stage 4 metastatic prostate cancer, which has now climbed all the way up my spine and into my ribs and femurs, I have something to say about PSA screening.
Since the symptoms of prostate cancer seldom appear until its late stages, there is normally just one way of finding out if it may be coming over the horizon: periodically measuring the level of the Prostate Specific Antigen (PSA) in the blood, which should normally be well under 10.
But just over five years ago, in May of 2012, the USPS Task Force gave PSA testing a grade of D, meaning that it probably “has no net benefits or that the harms outweigh the benefits.” In response to this widely publicized advice, which my internist promptly passed on to me, I stopped my PSA testing cold—at age 73, well above the age at which the Task Force recommends no screening.
Nearly five years later, signs of major fatigue led me to get my PSA re-checked. Though it had been something like 6 when last checked, it had now climbed to 65, and further tests—a CAT scan plus a bone biopsy—confirmed that cancer had not just entered my prostate gland but also crawled up into a good deal of my skeleton, as I could plainly see in a rather ugly picture of it.
So five years after the Task Force gave PSA testing a D, what do you suppose has happened to that grade?
We don’t yet have a definitive answer, but the Task Force has nonetheless drafted a new set of recommendations. For men ages 55 to 60, it has now raised its grade for PSA testing from D to C, which means that testing might do you more good than harm. But while PSA screening is now said to offer “a small potential benefit of reducing the chance of dying of prostate cancer,” it can still lead—we’re told-- to “false-positive results that require additional workup, overdiagnosis and treatment, and treatment complications such as incontinence and impotence.” In other words, the Task Force is still steering men away from the PSA test. And it’s dragging away men over 70—men like me. For us, we are told, the Task Force “recommends against PSA-based screening for prostate cancer”: a recommendation that Jane Brody has passed on to the millions of readers of the New York Times.
With Ms. Brody and the Task Force I beg to differ. Strenuously.
In 2012, when I stopped getting PSA-tested, I was 73. According to Dr. Charles Ryan, Thomas Perkins Distinguished Professor in Cancer Research at the University of California / San Francisco, an unusually aggressive cancer might have developed between annual PSA screenings even if I had kept on getting them. But at the very least, such screenings would have raised my chances of detecting the cancer while it was still within the prostate—before it started working its way up my spine.
And what difference does this make? According to the latest set of facts and figures published by the American Cancer Society, 92% of prostate cancers are caught at the local or regional stage, when the cancer is confined to the prostate and nearby organs, and nearly all men who are diagnosed with such cancers live for at least 15 years afterwards. But among men with prostate cancer that has spread elsewhere—as mine has—the five-year survival rate is 29%. So at the age of 78, my chances of reaching 83 are statistically less than one in three.
I am not cowed by statistics. With the luck of my Irish genes (my father lived to 98 and my mother to nearly 102), I hope to live well beyond 83, and with the aid of hormone therapy, I have already recovered most of my normal energy—for the time being. But since metastatic prostate cancer is truly a life-threatening disease (the third leading cause of cancer death in American men), no one should underestimate its danger.
In light of this danger, consider the arguments against regular PSA testing for men over 55.
Chief among them is that it’s anything but foolproof. Since PSA is a protein produced by both cancerous and noncancerous tissue in the prostate, and since PSA levels can be pushed up by noncancerous conditions such as an enlarged or inflamed prostate, the meaning of a high PSA score can be hard to judge. In fact an abnormally high PSA score accurately identifies prostate cancer only about 25% of the time. So a high score can indeed be a false alarm leading to needless biopsies and other invasive procedures. And as the Task Force is still saying right now, a false alarm can also lead to complications such as incontinence and impotence. Why then even start going up this escalator?
My answer is simple. A PSA test is not the first step of an escalator leading irresistibly to needless complications. A higher than normal score is not a mandate for “needless biopsies” or any other procedure. It’s the first step of a stairway fitted with landings where you can stand as long as you want to weigh your options.
First, you need to know whether your PSA score is above the normal high for a man of your age and race (yes, race matters here too). Some studies put the highest normal PSA score for all men at 4.0, but since the prostate gland generates more PSA as you grow older, other studies have argued that the normal high ranges from 2.0 for an Asian American in his forties to 6.5 for Caucasian male in his seventies. (See http://www.medicinenet.com/prostate_specific_antigen/page4.htm#what_are_age-specific_reference_ranges_for_serum_psa).
Suppose, then, you’re a 75-year-old white male whose PSA turns out to be 9. Before doing anything else, let alone surgery, you can get extra tests of your blood and urine that may tell you more about your condition. If you and your doctor are still uncertain, you could get a biopsy. But even if that confirms the presence of cancer in your prostate, you may not have to do anything more than check it regularly thereafter. If the cancer is growing slowly, causing no symptoms, and staying within the prostate, you can start what has been called “active surveillance” by Dr. Peter Carroll of the University of California/San Francisco (https://www.ucsfhealth.org/education/interview_carroll_active_surveillance_for_prostate_cancer/). After a higher than normal PSA score, in fact, the Cancer Treatment Centers of America (CTCA) recommends a PSA test every three months and a biopsy every 15 months. If this sounds like over-testing, it’s still a long way from coping with stage 4 metastastic prostate cancer.
Of course my case could be called atypical. If only 1 in 15 men are diagnosed with prostate cancer, and if only 8% of those are found to have metastasized cancer, the average man’s chances of ending up with a cancer like mine are less than 1%. Even if we factor in my family history (my father and my oldest brother both had prostate cancer before I did), my chances rise to only 2 or 3%. But so far as I know, there are no statistics designed to measure the risks of indefinitely skipping the PSA test.
So here is my question for those who argue against annual testing for PSA. Given the simplicity of the test, does the risk of anxiety sparked by a fallible alarm, and the cost and trouble of a CAT scan, MRI, or biopsy required to verify or falsify this alarm, really outweigh the risk of letting a cancer grow undetected for years on end until it invades the skeleton?
For now the Task Force says, in effect, yes: PSA testing is probably not worth the risk of all the trouble it may lead to. But according to Dr. Ryan, the number of men diagnosed with metastatic prostate cancer has ticked up since the Task Force first discredited the PSA test. Also, along with several other major organizations devoted to medicine and health, the Cancer Treatment Centers of America is definitely recommending the test-- not just for old geezers like me but for middle-aged men like my own son Andrew (a fitness specialist in superb physical condition), starting in their early forties.
Believe me: it’s much better to know what’s going on down there than to live in ignorance for years on end—as I did.