All Routine PSA Tests For Prostate Cancer Should End, Task Force Says
There they go again — those 17 federally appointed experts at the U.S. Preventive Services Task Force are telling American doctors and patients to stop routinely doing lifesaving tests.
Or at least that's the way some people look at the task force's latest guidelines on prostate cancer screening, which say doctors should stop doing routine PSA tests on men of any age. (The task force earlier recommended an end to testing of men over 75.) You can find the screening guideline in that current issue of Annals of Internal Medicine, along with editorials for and against it.
The American Urological Association pronounced itself "outraged" at the task force edict.
"It really is too extreme for them to say that all PSA testing should stop," fumes Dr. William Catalona, a Northwestern University urologist and PSA testing pioneer. "If all PSA screening were to stop, there would be thousands of men who would unnecessarily suffer and die from prostate cancer."
Catalona insists the evidence suggests routine PSA screening prevents as many as 40 percent of prostate cancer deaths by catching the disease when it's early and curable.
No way, says Dr. Michael LeFevre, a task force member who is professor of family practice at the University of Missouri.
"We think the benefit is very small," LeFevre told Shots. "Our range is between zero and one prostate cancer death avoided for every thousand men screened." By comparison, he says, the lifesaving benefit from colorectal cancer screening is two to 10 times higher.
LeFevre doesn't deny PSA screening saves lives. It's just that the benefit is much smaller than screening advocates think, he says. His best case: Widespread PSA testing might avoid between 1,400 and 2,800 prostate cancer deaths among 28,000 US men who now die of the disease. That's 5 to 10 percent.
"I don't want to take lightly any one of those lives," he says. "And if prostate cancer screening was harmless and nobody suffered the consequences on the opposite side, then I'd say, 'Well, why not?' But unfortunately, that's not the case."
The task force says up to 20 percent of men screened every year for 10 years will get a result that sends them to the biopsy suite. When cancer is found, nearly 90 percent will have surgery, radiation or hormone therapy, and up to one-third will end up with urinary incontinence, impotence or bowel problems.
Death from prostate cancer is a worse harm, for sure. But the task force says most of the men treated for cancer found through PSA screening would never have had a problem with the disease if it hadn't been found.
"A goodly proportion of men who have localized prostate cancer actually have a disease that will never kill them if left alone," says Dr. Otis Brawley, the American Cancer Society's chief medical officer. "More than a million men were needlessly cured of their prostate cancer over the last 20 years."
Brawley says this notion — experts call it "overdiagnosis" — is hard for most people to grasp, including cancer doctors (or perhaps especially cancer doctors). "What the Preventive Services Task Force is suggesting is contrary to all our prejudices," he told Shots. "We've all been taught that the way to deal with cancer is to find it early and cut it out."
He especially hopes the new guidelines will put a stop to mass PSA screening by mobile vans at shopping malls and hospital-sponsored "health fairs."
Brawley has been beating that drum since 1997, when an especially candid hospital marketing director bragged to him about the financial advantages of his institution's free PSA screening sessions. He recounts the story in his recently published book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.
"The marketing guy was really proud of his prostate-cancer-screening business plan," Brawley told Shots. "If they screened 1,000 men at the mall ... they got 135 guys coming in [to the hospital's clinics] to figure out why they had an abnormal test. And they would end up collecting an average of $3,000 per guy off of that."
From there, many biopsies would reveal prostate cancer, and nearly all of them would have surgery or radiation, he says. The ones who got radiation, the marketer told Brawley, "reimbursed at almost $80,000 a guy."
"I asked him, 'How many lives will you save if you screen a thousand guys?' " Brawley recalls. "And he took his glasses off and looked at me as if I was a fool and said, 'Don't you know, nobody knows if this stuff saves lives? I can't give you an estimate on that.' "
Brawley says some PSA screening fairs are sponsored by the makers of diapers for incontinent adults, apparently because they know many men with abnormal PSAs will eventually suffer treatment-related urinary problems. "I don't know if screening saves lives, but I sure know it sells diapers."
A Matter Of Semantics?
Brawley is himself an expert in prostate cancer treatment. And as opposed as he is to indiscriminate mass screening, he says he's not against PSA testing if doctors and patients go into it with open eyes, after a frank discussion of potential harms and benefits.
But while he thinks the Preventive Services Task Force "got it right," he says it needs to do a better job of explaining itself. As in the mammography screening controversy of 2009, the task force's analytical language leaves it open to the charge that it's unsympathetic to men's prostate cancer fears and diagnostic dilemma — coldhearted even.
"I wish the task force's wording were a little bit more user-friendly," Brawley says.
Instead of saying that doctors should stop doing PSA "routinely," he says, maybe it should have said they shouldn't do them "automatically."
That leaves the door open to a doctor-patient discussion about the pros and cons. And that's exactly what the task force says it wants to do.
AUDIE CORNISH, HOST:
From NPR News, this is ALL THINGS CONSIDERED. I'm Audie Cornish. First this hour, we wade into a debate over medical testing - when it's warranted, and when it's not. Today, a federally sponsored task force said men over the age of 50 should not be routinely offered a test for prostate cancer. That's a test the vast majority now get. The American Urological Association called the new guidelines outrageous and irresponsible. And as NPR's Richard Knox reports, it's not the first time this task force has found itself in the middle of a medical controversy.
RICHARD KNOX, BYLINE: The U.S. Preventive Services Task Force is a group of 17 people who are experts in analyzing medical evidence. Nearly three years ago, it kicked up a storm when it said women under 50 shouldn't get routine mammograms. The new prostate cancer guidelines, previewed last fall, are more sweeping. They say men of any age should not routinely get a blood test for PSA. An elevated PSA may signal prostate cancer - or not.
DR. MICHAEL LEFEVRE: Unfortunately, it is often sold as a test that can only do benefit and cannot do harm. And that's, simply, not true.
KNOX: Dr. Michael LeFevre says men generally aren't aware that PSA testing has pros and cons. He's a professor of family practice in Missouri, and a task force member.
LEFEVRE: We see community screenings. We see vans going around advertising: Men, come in, and this is your best chance to avoid a prostate cancer death.
KNOX: But the task force says for every 1,000 men who get a PSA screening test, one may avoid death because of it, but dozens more will get treatments for a cancer that would never have killed them. Nationally, LeFevre says PSA screening leads tens of thousands of men to get needless surgery and radiation while preventing perhaps 14- to 2,800 prostate cancer deaths a year.
LEFEVRE: I don't want to take lightly any one of those lives. And if prostate cancer screening was harmless and nobody suffered the consequences on the opposite side, then you'd say well, why not? But that, unfortunately, is not the case.
KNOX: Dr. William Catalona thinks the task force is dead wrong.
DR. WILLIAM CATALONA: I just think that what they have done is outrageous.
KNOX: He's a Chicago urologist who performs a lot of prostate surgery.
CATALONA: If the guidelines were implemented and if all PSA screening were to stop, there would be thousands of men who unnecessarily would suffer and die from prostate cancer.
KNOX: Catalona acknowledges the task force has an important mission: to weed out unnecessary tests, or say when they're doing more harm than good. But he says they shouldn't throw out the baby with the bathwater. The Preventive Services Task Force has its defenders, too.
DR. OTIS BRAWLEY: I am a prostate cancer doc, and I think they got it right.
KNOX: That's Dr. Otis Brawley. He's chief medical officer of the American Cancer Society. Brawley says prostate cancer is an exception to the rule that the best way to deal with cancer is to find it early and cut it out. Many, if not most, doctors believe that, and most prostate cancer patients do too. Many are convinced they owe their lives to a PSA test. But Brawley says a million American men have been treated for prostate cancer needlessly. Some men have localized prostate cancer that would never kill them, he says. Others have prostate cancer that kills them even when it's caught early. And a third group, well...
BRAWLEY: The real question is, is there a third group of men - and that is men who we can find the disease early and cure them, and give them a cure that they actually needed because the disease was a threat to their life. That third group of men, we still don't know if it exists, and that's the root of this whole question about screening.
KNOX: But as in the mammogram controversy, Brawley thinks the task force leaves itself open to the charge that it's too analytical, even coldhearted. He thinks it needs to do a better job of explaining itself.
BRAWLEY: I will admit to you that I wish the task force wording were a little bit more user-friendly.
KNOX: Instead of saying that doctors should stop doing PSA tests routinely, maybe it should have said that they shouldn't do them automatically. That leaves the door open to a doctor-patient discussion about the pros and cons. And that's exactly what the task force says it wants to do.
Richard Knox, NPR News. Transcript provided by NPR, Copyright NPR.