Nearly 20 years ago, Stormin' Norman Schwarzkopf, the general fresh off his Gulf War triumph, graced the cover of Time magazine. He then led the charge in a new battle: the fight against prostate cancer. "Men don't like to talk about it, but 1 in 5 will get it," the magazine cover read. "There's a simple blood test everyone should know about. Here's why."
The story focused on the prostate-specific antigen, or PSA test -- the same procedure at the center of a controversy since the U.S. Preventative Services Task Force analyzed the data and suggested the screening no longer be routine for healthy, middle-aged men. The task force concluded that "PSA-based screening is associated with detection of more prostate cancers; small to no reduction in prostate cancer-specific mortality after about 10 years; and harms related to false positive test results, subsequent evaluation, and therapy, including overdiagnosis and overtreatment."
So, if screening doesn't save lives and may result in harm, why do it at all? This counsel has prompted an emotional reaction, perhaps because most people can't adjust to the idea that finding cancer early can cause more harm than help. That seems contrary to every cancer-related public service announcement we've ever heard.
The data, however, indicate that there is little, if any, evidence that PSA screening has reduced deaths. The science, instead, shows that many men have undergone treatment for tumors that would not have killed them and suffered serious consequences as a result.
A 2009 U.S. study in the New England Journal of Medicine found that after seven to 10 years of follow-up, the rate of death from prostate cancer was very low and did not differ significantly between men who received annual PSA and digital prostate exam screening and men who received usual care. It should be noted, however, that many of the men in the control group who did not undergo a planned active screening protocol with PSA testing, did have PSA levels determined by their physicians as part of usual care.
Also, a European collaborative study found similar results to the U.S. program, although a Swedish site in that study did report a decrease in prostate cancer deaths with PSA screening in men ages 50 to 64. Thus, although the data suggests that PSA screening may not save as many lives as we previously thought, the studies were not of the highest quality and there were suggestions that PSA may be helpful in some age groups. And these studies are just referring to using the PSA as a screening test for the general adult male population. Men with a strong family history of prostate cancer, urinary tract symptoms or symptoms that could be due to prostate cancer, or men who have had prostate cancer and are monitored by PSA tests should still have the screenings performed.
The test itself has a problem in that it is not specific for prostate cancer. An elevated PSA could indicate a common condition called benign prostatic hyperplasia, an infection or inflammatory condition of the prostate.
The major problem is what we do with the information. An elevated PSA is often followed by an ultrasound examination, then by a dozen or so biopsies of the prostate.
Men treated for prostate cancer -- through surgery to remove the prostate or with radiation -- often suffer side effects that degrade their quality of life: incontinence, bowel problems and erectile dysfunction among these. Even a prostate biopsy, a potential out-patient follow-up procedure to an elevated PSA result -- carries greater risks of hospitalization, infection and other complications for men who undergo this procedure, as compared with those who did not, a recent study found.
"We have invested over 20 years of belief that PSA testing works," the American Cancer Society's Dr. Len Lichtenfeld wrote on his blog when the panel's recommendation came out. "And here we are all these years later, and we don't know for sure."
He goes on to point out that men have been tested, probed, operated on, radiated and billions of dollars have been spent. And what's left now, he asks. "A mess of false hope?"
Thousands of us have marched for a cure, donated and targeted cancer as an enemy to be defeated -- not a disease to be allowed in our bodies once we know it's there. Most of us probably feel as Stormin' Norman did in 1994: "I'm not a type-B personality who knows I have a cancer growing inside of me and can live with the knowledge ... I go into a kung-fu attack position when I go through the door of a hospital."
But for most men with elevated test results, living with knowledge -- and cancer -- may be the correct thing to do.
A High PSA, Now What?
The PSA test became the prime weapon to battle prostate cancer due largely to urologist William Catalona of the Northwestern University medical school. While a Johns Hopkins resident in the mid-1970s, the only tool he and others had available to them to find prostate cancer was a digital rectal exam. By the time this cancer could be detected this way, tumors already were advanced and even surgery wasn't promising.
Because he treated so many advanced-stage patients in his clinic, he sought a way to detect the disease early, while it better could be cared for. He noticed men with the most advanced cancers had the highest PSA levels. He first checked his own patient records, then conducted a study and published the results in the New England Journal of Medicine. The simple blood test gained wide support and now routinely men older than 50 undergo screening.
While Dr. Catalona acknowledged in a Los Angeles Times interview earlier this year that many prostate cancers are harmless, he raises an excellent point: it's not possible now to detect which cancers will be fatal and which will progress slowly and harmlessly.
Once patients learn they have cancer, an immense pressure builds to attack it. That reaction may stem from the patient's fear or fears of his family and loved ones. And that's where serious procedures and side effects can follow.
The Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute is one of the first sites in a nationwide study, with Johns Hopkins University, to examine an "active surveillance" strategy. It calls for physicians to keep close watch on a man's cancer, and when it has changes, to treat it appropriately. Using results of a recent study, showing a third of men in "active surveillance" had a cancer that progressed to the point that treatment was recommended, it's possible to put patients into risk categories. This may be a better approach then leaping in to treat men at very low risk of developing a deadly form of prostate cancer.
Scientists also are improving the way we look at cancer: rather than seeing it as a single, monolithic illness, they're recognizing it as a collection of diseases, each with varying DNA weaknesses that make them more or less vulnerable to treatment. Someday soon there may be molecular-level tests that will allow us to discern which are fast-moving, lethal cancers and those that are more indolent and slow growing -- the type that so many men die with, but not from. Unfortunately, we don't have a test now for prostate cancer that allows us to make this discrimination, but it is very likely that we will have one in the not-too-distant future.
Gold Standard Testing
The current uproar over prostate cancer screening follows by just a short time a similar controversy for women over mammograms.
Two years ago, the same government task force called for women to start getting mammograms at age 50 not 40 -- then repeating the test every two years rather than yearly. The rationale then was much the same: after weighing risks and benefits, studies found that screening early and frequently more often led to psychological distress, unnecessary tests and biopsies -- without improving women's odds of survival.
The mammography advisory proved so hot that the panel delayed its counsel on prostate cancer for two years, hoping the science behind it would be correct and compelling. The storm rages on, however: a poll by Physician's First Watch drew 949 responses, with 56 percent agreeing with the panel and 44 percent opposed to reduced screening. Both sides cite sincere concern for patients. There also are financial concerns at play here -- for insurers and for those who screen and care for men with prostate cancer, with some physicians taking umbrage at assertions they harm or treat patients' unnecessarily.
Other ambitious testing programs, historically, have been linked to unnecessary treatment. The Mayo Lung Project found in the mid-1980s, and in follow-up with the same patients in 2000, that chest X-rays at frequent intervals failed to decrease the death rate from lung cancer. They did detect tumors that were not life-threatening. Besides causing unnecessary worry for patients, they also led to expensive and risky biopsies and surgeries.
Consequences of Over-Testing
Prostate cancer care for men, of course, is a sensitive matter because of its potential effects on their sexuality (similar to challenges related to breast and gynecological cancer therapies and their possible effects on women's sexuality).
A study in the September issue of the Journal of the American Medical Association found that with more men surviving early stage prostate cancer, quality of life issues have become increasingly important when considering treatment options -- especially sexual function.
The study found that among men who had their prostates removed, 40 percent recovered sexual function within two years of their surgery -- which means more than half did not. For men who underwent external radiation, 58 percent maintained sexual function and 63 percent kept it after brachytherapy. The good news is, factors such as age, PSA levels, use of nerve-sparing surgical techniques and hormone therapy all influence prospects for sexual health post-treatment. Men with a low baseline PSA level are more likely to retain sexual function after surgery and radiation, while those with higher levels often have more extensive cancers or larger prostates that will affect surgical approaches and require higher doses of radiation.
The key with cancer therapy, as in all medical care, is that men and their physicians must speak frankly and openly about treatment options and what may occur after. Despite the ubiquitous drug ads, men clearly are uncomfortable talking with their doctors about erectile dysfunction -- this same study also found that most men who lost sexual function after prostate cancer treatment had not explored any medical options to address their sexual health.
The American Cancer Society, which several years ago reviewed the same data that the federal health panel based its recent advisory upon, also emphasized how important it is for candid discussion between doctor and patient. Its standing advice is that, given no clear evidence that PSA testing saves lives, the best solution is for patients and MDs to frankly discuss the screening's benefits and risks.
That's also very close to what the U.S. Preventive Services Task Force panel recommends -- and the research and candor called for in this instance will, honestly, become a bigger part of what will be expected of informed patients and doctors as this country seeks to curb the soaring national costs of healthcare. The patient-physician relationship is more crucial than ever, especially as we all try to figure not only what tests and care actually benefit us but also what we can afford. As even more advances occur in science and medicine, we will see the old, one-size-fits-all approach to care vanish, as the concept of personalized medicine matures. If the choices weren't baffling before, they may be ever more bewildering. If you don't have a doctor who is knowledgeable, whom you trust, whom you feel comfortable talking with about any aspect of your health and who you feel hears your concerns, then look for a new doctor, pronto.
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