The Prostate Cancer Testing Dilemma
Treating non-life-threatening cases risks lifelong incontinence and erectile dysfunction
En español | A urologist acquaintance once confided his greatest medical fear: that a high PSA would lead to a diagnosis of stage 1 prostate cancer (no spreading beyond the gland).
Only 10 percent of early prostate tumors become life-threatening, he explained, but there's no way to distinguish them from the 90 percent that aren't. Without treatment, he thought he would have a 10 percent chance it might be fatal. But treatment side effects include a high risk of lifelong incontinence and erectile dysfunction, and he believed there would be a 90 percent chance that treatment would be unnecessary. He confessed he wouldn't know what to do.
I recalled his dilemma while reading Richard J. Ablin's just published The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster. Ablin is the scientist who, in 1970, discovered PSA, or prostate-specific antigen — a protein whose level in the blood usually spikes upward in men with prostate cancer. Yet today Ablin accuses PSA of being a lousy test for prostate cancer because:
- PSA does not diagnose cancer. A man with a low PSA can have cancer, yet most men with high PSAs do not.
- A high PSA can be caused by many other things besides cancer — among them infections, sex (partner or solo), sitting for long periods and normal age-related prostate enlargement.
- Prostate cancer is virtually inevitable with age; autopsy men over 85, and almost 100 percent will show it. Hence this medical adage: Some men die from prostate cancer, but all old men die with it.
- High PSAs lead to more than 1 million annual prostate biopsies, which in turn cause 100,000 men a year to seek treatment for prostate cancer; most of the 100,000 have tumors that will never endanger their lives.
Ablin, who refuses to have his PSA tested, goes so far as to call PSA screenings "a hugely expensive public health disaster."
PSA testing has hardly been a financial disaster for urologists, however; they practically mint money from costly biopsies and surgical treatment. Not surprisingly, many urologists champion routine PSA screening. But other doctors, meanwhile, have cooled on the test:
- In 731 men with stage 1 prostate cancer, University of Minnesota researchers either removed the gland (radical prostatectomy) or did nothing (watchful waiting). After 12 years, the treated men's death rate from prostate cancer was less than 3 percent below those not treated.
- Scientists at Washington University in St. Louis did yearly screenings of the PSA levels in 38,000 men. At the same time, 38,000 control subjects were tested less frequently — if at all. "After seven years, the death rate from prostate cancer did not differ significantly between the two groups."
- Dutch researchers tested PSA in some 91,000 men every four years; a separate group of the same size was never tested. After nine years, the prostate cancer death rate was slightly lower in the tested group, but the testing had also resulted in a great deal of overdiagnosis and overtreatment.
Of course, sometimes treatment is necessary. Many men, including a close friend of mine, swear that PSA testing saved their lives — even if it cost their erections and necessitated underwear pads.
In 2012, the U.S. Preventive Services Task Force, an expert panel that advises the Department of Health and Human Services, recommended against routine PSA testing. The American Urological Association initially expressed "outrage" but has since modified its position, saying PSA testing should depend on men's "values and preferences." Of course, most men simply do what their doctors say — and most doctors recommend annual PSA testing.
So what's a man to do: Test PSA or not?
I get screened, but I've also taken steps to reduce my risk. The best-known risk factors — age, family history and race — cannot be changed. (African American men are at unusually high risk.) But many studies show you can substantially reduce your risk of prostate cancer by:
- Eating at least five — but preferably eight to 10 — daily servings of fruits and vegetables;
- Cutting back on meat, cheese and whole-milk dairy.
After my own PSA reading came back elevated a few years ago, I found myself bent over and being probed with what felt like a baseball bat. Sure enough, the biopsy showed worrisome precancerous cells, prompting my doctor to schedule another biopsy six months later.
During that interval, I swilled tomato juice; vitamin A-rich tomatoes are the food most closely linked to reduced risk of prostate cancer. I also gobbled salads and reduced my (already-low) consumption of meat, cheese and ice cream. The second biopsy was negative, so I didn't have to make the tough choice. But in fact I had already made it: Had my doctor discovered prostate cancer confined to the gland, I would have opted for a course of watchful waiting; only if it threatened to spread beyond the gland would I have considered seeking treatment.
Michael Castleman, publisher of the website GreatSexAfter40.com, writes about sex for AARP.
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