But Ian Thompson, M.D., director of the Cancer Therapy & Research Center at the University of Texas Health Science Center at San Antonio, still believes screening can save lives. He says that both major studies had significant flaws, and he notes that the death rate from prostate cancer has dropped steadily since the PSA test was popularized in the early '90s.
Brawley, however, points out that prostate cancer deaths have been dropping all over the world — even in countries where the PSA test is rarely used, such as Great Britain. He credits the progress to better treatments and, perhaps, a change in the way doctors record cause of death.
The benefits of PSA tests may be murky, but the risks are undeniable. Brian Hines is right: A positive PSA test can be a ticket for treatment. It often starts with a needle biopsy, a procedure in which a doctor inserts a needle — usually through the wall of the rectum — to remove tissue samples from the prostate. The procedure is uncomfortable and can cause bleeding and infection. If the biopsy confirms cancer, the next step is often radiation or surgical removal of the prostate, a serious operation that can leave a man facing impotence, incontinence or both.
It seems obvious that catching a cancer early gives patients the best chance to beat their disease. But prostate cancer isn't like a lot of other cancers. It is often very small and slow-growing, with no intention of spreading. And some prostate cancers grow extremely fast — so fast that it's hard to catch them before it's too late.
"Many men deeply believe the PSA test saved their lives. But for many men, that's almost certainly not the case," says Barnett Kramer, M.D., director of the National Cancer Institute's Division of Cancer Prevention.
Unfortunately, there's no way to know for sure whether any particular cancer is harmless or dangerous while it's still in the prostate, so many men end up getting treated just to stay on the safe side. But many experts now argue that even if cancer is detected, men still need to weigh the risks and benefits of treatment. They advocate a period of "watchful waiting" to see whether symptoms arise, or "active surveillance," which involves exams, tests and biopsies that monitor the cancer.
So what to do? Brawley urges men to watch for signs of prostate problems. And men can still get the PSA test if they want it. "You need to go with how you feel about prostate cancer," he says. Some doctors strongly encourage PSA testing for people at high risk for the disease, including African Americans and men with a family history of the disease.
Brawley is a PSA skeptic, but he's a firm believer in a prostate-friendly lifestyle. While there's no firm proof yet that a man can do much to prevent this cancer, Brawley says, "I believe that eating a diet high in fruits and vegetables, exercising three to five times a week, and keeping a BMI [body mass index] around 25 are all good for prostate health." He adds, "I wish I could know it. But I believe it."
Chris Woolston is a health writer whose work has frequently appeared in the Los Angeles Times.
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