A top panel of U.S. medical experts has issued a final decision on a long-debated men’s health controversy, concluding that no man of any age should routinely be screened for prostate cancer using the popular PSA test.
The U.S. Preventive Services Task Force gave the prostate-specific antigen test a grade of D, saying that the risks of population-wide screening outweigh the benefits.
“There is convincing evidence that the number of men who avoid dying of prostate cancer because of screening after 10 to 14 years is, at best, very small,” wrote the panel charged with evaluating prevention and evidence-based medicine.
While the panel signaled its decision in a preliminary report last year, the ruling published Monday in the Annals of Internal Medicine represents the final act in an emotionally charged debate that could affect millions of men. Medicare and private insurers, for example, could use the conclusion to justify ending reimbursements for the tests.
Today, most men who receive regular medical care have PSA tests, typically starting at age 50, though sometimes younger. But the panel, citing large epidemiological studies from both Europe and the United States, said the benefits of PSA screening and early treatment amount to less than one prostate cancer death avoided for every 1,000 men screened.
The test, which measures a protein in the blood, does not diagnose cancer. It looks for a tell-tale sign that cancer may be present. (The other commonly used technique, a DRE, or digital rectal exam, is used by doctors to feel for prostate abnormalities that have already become palpable.) A positive test usually kicks off a series of events such as a confirming biopsy, and then treatments including surgery, radiation, chemotherapy and hormone deprivation.
Because the test often results in false positives, and because it can’t tell how aggressive or benign a cancer may be, doctors and patients are often in the dark about whether the tumor requires treatment. So, out of caution, most men with positive PSA tests are biopsied and, if cancer is found, treated.
“Thus,” the task force stated, “many men are being subjected to the harms of treatment of prostate cancer that will never become symptomatic. PSA-based screening for prostate cancer results in considerable overtreatment and its associated harms.”
Typical side effects of treatment include impotence, incontinence, even death.
But Rick Lyke, a 51-year-old Charlotte, N.C., public relations executive, is furious about the decision. “They’re playing Russian roulette with men’s lives!” he said.
Lyke was tested in 2007, though he didn’t want to be tested at all. At 47, he figured he was too young to be screened for prostate cancer.
But a work colleague was then battling the disease and strongly urged a group of his male co-workers to do it.
“I went in for my physical, and my doctor did the finger thing, and said ‘You’re fine,’” Lyke recalled.
He’d promised his friend he’d get a PSA, though, so he insisted the doctor check the box on the lab test menu. The number came back extremely elevated, and a biopsy confirmed Lyke had prostate cancer. He opted for surgery and, after a short period of incontinence and impotence, made a full recovery. Meanwhile, his friend had died.
“I could be dead, too,” he said. “I am living proof” the task force is wrong, he added.
Retired University of Washington professor Jim Kiefert of Olympia, Wash., was equally upset by the ruling.
“They do not give a damn about you,” he said of the task force. “They use population statistics to justify not giving PSA tests. They forget about people at the other end of the Bell curve."
Kiefert, now 73, was at the far end of the curve after his first PSA test at 50 led to a diagnosis of metastatic prostate cancer. He’s waged a battle against the cancer ever since, including surgery, radiation, and hormone deprivation therapies.
“So how do I feel about it?” he said. “I wish I could have gotten a PSA test at 40 or 45 and gotten that cancer before it escaped the gland.”
The developer of the PSA test, Dr. William Catalona, director of the clinical prostate cancer program at Northwestern University’s Robert H. Lurie Comprehensive Cancer Center, was also adamant that the task force had made a huge error. “PSA is really all there is out there for detecting prostate cancer early,” he argued in a rebuttal.
Though the task force did not consider the costs of testing, diagnosis, and treatment in its deliberations, and is an independent body, advocates such as Lyke, Kiefert and Catalona accuse members of being motivated by a desire to slow rising health care expenditures.
But Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the panel’s decision in an accompanying editorial.
“Many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found,” he wrote. “There is little appreciation of the harms that screening and medical interventions can cause.”
Just about every man who undergoes treatment after a PSA test will say that the test saved his life, Brawley said, though, often, “he would have been just fine had the cancer never been detected and treated.”
Brawley said in an interview that routine PSA testing is an example of our “irrational health care system.”
He believes that agitation to continue testing is driven, at least in part, by financial incentives. Catalona, for example, holds patents on PSA testing technology and consults for industry. Lyke’s organization, Pints for Prostates, has received donations from Dendreon, maker of a prostate cancer drug. He was a patient of Catalona’s.
New York University bioethicist and frequent msnbc.com contributor Arthur Caplan agrees that economic interests are present, but thinks the debate represents a genuine difference of opinion.
“There just isn’t enough information to tip the scales absolutely in one direction,” he said. “While the recommendation is negative, there are still those doctors who believe a bad test is better than no test.”
All sides agree on one thing, though. The task force’s conclusion may not change much. Both Caplan and Brawley said urological surgeons, oncologists, testing companies, medical equipment makers will lobby to neutralize any effect. Some doctors will mount a talking campaign to encourage their patients to continue being tested.
“What does that conversation even look like?” Caplan asked. “I mean, what we’re saying is, ‘Talk to your doctor and see if he doesn’t believe us.’”
And when patients do talk to their doctors, those doctors may still be likely to check the box for the test.