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Influential Panel Gives Thumbs Down To Routine Prostate Cancer Test

Chicago attorney Tom Hayward suffered a raging infection after a prostate biopsy. He had to be hospitalized, but has since recovered. (Icoi Johnson for NPR)

The same group that caused a ruckus by recommending against mammograms for women in their 40s is about to tell men that a routine blood test for prostate cancer does most of them more harm than good.

The problem is that the test doesn't do enough to save lives and subjects many men to additional tests and surgery. The side effects, including impotence and incontinence, outweigh the benefits for men in good heath, according to reports about the findings of the U.S. Preventive Services Task Force.

An independent group of medical experts, the USPSTF is in the business of grading the evidence for common tests and procedures. Under the auspices of the Agency for Healthcare Research and Quality, the group's decisions increasingly serve as guidelines for what doctors do and what insurers and the government will pay for.

Update 3:05 p.m.: The USPSTF draft recommendation against routine PSA screening has been posted here.

The USPSTF has been working on the PSA test for a while. In fact, the group had pretty much reached a decision in 2009 that the evidence for routine PSA testing should be graded "D" (which constitutes a recommendation against the service), according to an article coming in The New York Times Magazine this Sunday and already posted online.

But the controversy such a recommendation is sure to cause led to a postponement of votes on it, Shannon Brownlee and Jeanne Lenzer report in the story.

Now it's finally coming out, perhaps as early as today. "The harms studies showed that significant numbers of men — on the order of 20 to 30 percent — have very significant harms," pediatrician Virginia Moyer, chairwoman of the task force, told the Washington Post.

This year, about 241,000 cases of prostate cancer are expected to be diagnosed, according to estimates from the American Cancer Society. About 34,000 men will die from it. More than 20 million U.S. men have their PSA's tested each year.

A federally funded study presented at a meeting of urologists this spring found that, overall, early surgical removal of the prostate was no better than waiting to see how the cancer would progress. And there were more side effects among men who had surgery.

In a Times editorial published in March, Dr. Richard Ablin, who discovered prostate specific antigen, lamented the overuse of the test. Yes, the test has its place, he wrote, to monitor men after treatment for prostate cancer and in screening men whose family histories put them at high risk.

"But these uses are limited," Ablin concluded. "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."

While the USPSTF's decisions carry a lot of weight, a separate report out today shows the limits of its ability to change medical practice. The Center for Public Integrity finds that 40 percent of Medicare spending on cancer screenings, or about $1.9 billion over five years, is wasted on tests, including PSA, for people older than the cutoff recommended by the USPSTF.

Opposition to a change in PSA recommendations is certain. Dr. Benjamin Davies, a urologist and cancer specialist at the University of Pittsburgh Medical Center, tweeted this morning:

the data for screening healthy patients <65 is strong, not debatable, and level 1. Hard to tweet all of the evidence

He called the USPSTF's determination "soulless" and faulted some of the evidence the group, including this Swedish study, used to make its decision.

The American Urological Association disputed the task force's findings. The urology group's president said in a statement that "it is our feeling that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients."

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Transcript

GUY RAZ, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Guy Raz.

MELISSA BLOCK, HOST:

And I'm Melissa Block.

Anytime the medical community casts doubt on cancer screening methods, people get understandably alarmed. It happened two years ago when a government health panel recommended against mammograms for women in their 40s. Well, now that same group, the U.S. Preventive Services Task Force, is recommending against a blood test for prostate cancer. It says healthy men of all ages should not get the PSA test because scientific studies have proven there's no benefit to the screening.

Dr. Timothy Wilt is a member of that task force. He's an internist and a professor at the University of Minnesota School of Medicine. I asked to explain what's wrong with the PSA test.

DR. TIMOTHY WILT: Men often think it's such a simple blood test, but it's the downstream consequences of that. So if the test is abnormal, men undergo biopsies. Biopsies can result in pain, infection, inflammation. And the most important problem is that it can detect cancers that are small, slow-growing and would never cause problems in a man's life.

But because when a man is diagnosed with cancer, it's hard for us to determine which one of those are potentially bothersome. And the vast majority of those are not. But almost all men, about 90 percent of the men who are found to have prostate cancer due to PSA testing undergo treatment for prostate cancer. And prostate cancer treatments have real harms.

BLOCK: And what are the harms that you're talking about that might result from the treatment?

WILT: The harms include about 5 out of 1,000 men will die within one month of prostate cancer surgery, due to the surgery. About 10 to 70 men in 1,000 will have a serious complication from surgery. And those include a heart attack, a blood clot or surgical complications. And while those are relatively uncommon, other side effects such as urinary, bowel and sexual dysfunction are quite common - somewhere between 20 to 30 percent of men - and those often persist for a long period of time.

BLOCK: Would it be fair to say, Dr. Wilt, that the problem isn't so much the initial PSA test itself, it's the problem of what follows, the treatments themselves that can be risky or have these complications?

WILT: That's true. The PSA blood test itself is just a blood test. But it starts a cascade of events that are very difficult for clinicians and patients to close their eyes to. And so, the harms related to PSA screening appear to outweigh the benefits.

BLOCK: Dr. Wilt, prostate cancer, I gather, is the second most-common form of cancer in men after skin cancer - something like 240,000 new cases every year. I was reading the comments from a man named Skip Lockwood, who heads an advocacy group called Zero. And he says that the panel's decision here, in his words: Condemns tens of thousands of men to die.

How would you respond to Mr. Lockwood and advocates such as him?

WILT: Yeah, we appreciate the sincerity of individuals who believe that a PSA blood test has prolonged their life. But the common belief that it does is not supported by the scientific evidence. What we know from the good medical science is that PSA testing does not reduce prostate cancer deaths or help a man live longer.

BLOCK: I wonder if a recommendation like this, against testing, sort of bucks the feeling that many of us have, which is that we want to know what's going on inside of us, we want to be tested, we're used to a lot of testing.

WILT: I think it's often difficult for individuals to understand that some screening tests may not be useful and can actually be harmful. And our recommendations are intended to inform physicians, to allow them to help make the best discussions with their patients to improve their health and well-being.

That's what I do with my patients all the time. I tell them, let's talk about whether this PSA blood test can help make you live longer and live better. And what I'll tell them is that I recommend against it. And most of them are very, very fine with that.

Others will say, you know, Doctor, I'd still like to get that PSA blood test. And I say, let's do that. Let's talk about the results. Let's work and see what we can do based on those results, where we go from here.

BLOCK: The fear there are though would be that if a panel such as yours recommends, or issues guidance against these tests, that insurers may not cover the cost of the test, Medicare might not cover it.

WILT: Our recommendations don't consider cost and are not intended for health insurance coverage. In fact, Medicare currently, by law, covers the PSA blood test. Our recommendations focus on the clinical science intended to try and help men and their physicians balance of benefits and harms of prevention and help promotion strategies.

BLOCK: Dr. Wilt, thank you for your time.

WILT: Thanks so much for your interest.

BLOCK: That's Dr. Timothy Wilt. He's a professor at the University of Minnesota School of Medicine. And he's a member of the government health panel that has issued a draft recommendation against the PSA blood test for prostate cancer. Transcript provided by NPR, Copyright NPR.

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