The Prostate Controversy: Should I get tested?
“Most men are going to their graves with prostate cancer instead of from prostate cancer.”
The prostate cancer testing controversy has raged on for over a decade. The prostate controversy parallels the mammogram controversy (see the Harms of Mammography blog) although mammograms look stellar when compared to PSA testing. Before we get started, I want to state a few key terms, so that we are all on the same page.
PSA – Prostate Specific Antigen testing. This is a simple blood test that has been routinely checked in men over the age of 50 for many years.
DRE – Digital Rectal Exam is the examination of a patient’s rectum with a finger. The test assesses for rectal cancers, hemorrhoids, and prostate abnormalities. The small amount of stool present in the rectum is tested for blood after the exam which can be an early sign of colon cancer.
Screening Test – A screening test is a test that is performed on the general population when they are without symptoms and are at average risk. A screening test does NOT apply to high risk individuals or patients with symptoms. For instance, if your father had fatal prostate cancer at a young age, then you are not considered to be in a “screening” population. You are at high risk and need more aggressive testing than others at average risk. Or, if you are having trouble urinating or have noticed blood in your semen, then a PSA test is not considered a screening test.
Since the PSA test was discovered, it has been the subject of numerous studies. In 2006, a group of scientists combined all of the data from previous studies and analyzed the results. There were a total of about 350,000 men who were between the ages of 50 and 74. All men were followed for 7 – 15 years. The patients were divided into “PSA Testing Groups” and “Control Groups.” The PSA Testing Group received annual PSA levels and subsequent diagnostic tests needed. The control group did not have any PSA levels drawn nor did they get any further studies or interventions performed on them.
End Result: Both groups lived the same amount of time and died at the same ages.
This is a real head scratcher. We all thought that getting tested regularly meant that you are healthy and being responsible. Not according to this data.
There is a hidden and added harm to the shocking results listed above. Not only did the group that got yearly PSA tests live to the same age as the control groups, but they had further testing and interventions performed that were apparently unnecessary. If their PSA was abnormal, then they would get a Transrectal Ultrasound and 14 (or more) biopsies of their prostate. As you can imagine, an ultrasound probe inserted through your rectum is uncomfortable to say the least. On top of that, 14 biopsies of the prostate are taken since prostate cancer can hide in any portion of the prostate. The false positive rate of these biopsies is as high as 75%, and as many as 50% of men are over-diagnosed with prostate cancer from the transrectal biopsies.
If the biopsies return as abnormal or cancerous, then the male undergoes radiation therapy or radical prostatectomy (removal of the prostate). After all of these interventions, the likelihood of death was the same as without any testing or intervention! How can this be if they were saving lives by removing prostate cancer, and the other group was not even tested? The reality of it is that surgery and interventions can be harmful.
For example: Consider that one person is saved by prostate cancer treatment. In the same group, another person who was going to be saved by surgery gets hospitalized because of a surgical complication like rectal bleeding. The hospitalization leads to a drug-resistant pneumonia which in an elderly person who just underwent radical prostate surgery turned fatal. This adverse outcome negates the person who did manage to live longer.
This example illustrates why both groups lived the same length of time. For every person that was saved, another died early.
More ways to look at the same data:
One life is saved for every 37 cancers detected and treated. How would you like to be 1 of the 37 that underwent radiation or radical surgery for no reason in order for someone else to live longer?
For every 1,000 men screened, 0.1 life is saved. Yikes! In other words: You must screen 10,000 men before one life is saved. That is more men than I have in my practice! So, if I screen all of the men in my practice, none of them might benefit? Scary!
Over the years, many of the physician organizations have changed their position statements and recommendations regarding PSA testing. It is not surprising that the Urological association has the most aggressive approach to PSA testing despite their lack of evidence.
- USPSTF (United States Preventive Services Task Force):
This federal organization is supposed to be immune from bias since it is a panel of physicians from multiple specialties that evaluate all aspects of a test, including effectiveness, harm, benefit, and cost. They drive many of the guidelines that physicians live by.
The USPSTF organization recommends AGAINST PSA testing on men of any age. Through their analysis, they have determined that more people are harmed than they benefit.
- ACP (American College of Physicians):
Men aged between 50 – 69 years of age should be informed of the LIMITED POTENTIAL BENEFITS and the SUBSTANTIAL HARMS of screening for prostate cancer.
- ACS (American Cancer Society):
“The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their healthcare provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information.”
- American Urological Association (AUA)
“For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.”
Why is the medical field changing its opinion? Routine PSA testing used to be the healthy thing to do.
The medical field is changing its opinion because the PSA test has not demonstrated that it is helping the general population. We (physicians) knew in the beginning during its release that it was not perfect. We did not however have enough data to suggest everyone to get it annually. We marched ahead performing the test routinely anyway because we thought we were going to save lives. “We put the cart before the horse,” and it did not turn out as expected.
Is this change being forced upon doctors because of Obamacare?
No, this change has nothing to do with Obamacare, and this issue has been under controversy for many years even before President Obama was elected.
My PSA has always been normal. Should I keep getting it?
This is a difficult question to answer. You fall into the same category as everyone else. The trouble with PSA testing is not “What do I do if it is negative (normal)?” The real trouble is, “What do I do when it is positive (abnormal)?”
A positive test can cause you to lose sleep at night worrying about prostate cancer. A positive test could mean that you have a mild case of prostatitis (prostate gland infection) that you will need to take antibiotics for 4-6 weeks in order to “fix.” However, was a “fix” really needed for something that was not bothering you until the PSA was abnormal? A positive test may trouble you enough that you go see a Urologist and get a rectal ultrasound of your prostate with biopsies.
My PSA has always been normal, but it was abnormal this year. Now what?
The answer to this question is the same as the question above. You can take your chances, but it only takes one abnormal PSA to scare you into a Urologist’s office.
My PSA was abnormal, and I was diagnosed with prostate cancer and received treatment. Now, I am as healthy as a horse! The PSA test saved my life! What do you say about that, Dr. Oubre?
You are the 1 in 10,000 that was saved. I am happy that modern medicine was able to help you extend your life and enjoy many more great years with your family and loved ones.
The real question is whether you actually had aggressive prostate cancer that would have been fatal or a mild cancer that may not have ever metastasized or caused problems.
Most men are going to their graves with prostate cancer instead of from prostate cancer.
What about being on testosterone therapy? Do I need to get my PSA checked every 6 months or yearly?
This is an area that is also under controversy. There are studies on both sides of the aisle, so I will defer the answer to the physician prescribing you testosterone. One study showed that men with testosterone deficiency had higher rates of prostate cancer. Thus, if the testosterone levels were replaced, then the prostate cancer risk lowered.
Do I still need a DRE or rectal exam even though I am not getting my PSA tested?
This is also debatable. However, the data regarding rectal exams saving lives is worse than the PSA test. In fact, it is not recommended for physicians to do regular rectal exams unless there is a reason. After reading that, I bet many men breathed a sigh of relief. Men, you do not have to be scared to come to the doctor after you turn 50!
If physicians are not doing yearly prostate checks, then we are not performing a DRE (rectal exam). One of my concerns is that we are missing an opportunity to test the stool for blood (FOBT) which may indicate colon cancer. However, if you are getting your colorectal cancer screening routinely, this should not be an issue. There are currently 3 forms of colorectal cancer screening: Colonoscopy, Flexible Sigmoidoscopy, and Fecal Occult Blood Testing (FOBT). None of these screening exams rely on the physician’s yearly DRE or FOBT.
I did not screen my patient, and he was 1 of the 10,000 that had aggressive prostate cancer that turned out to be fatal. Would I have caught it if I had tested his PSA level?
This has to be the worst situation for a healthcare provider: a missed opportunity to save a life. Unfortunately, it happens and will continue to happen. It is sad, and it always causes regret. The part that I have to remember is how many people I would have harmed in the process to save that one person.
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