PSA Screenings Under Attack


Though common sense dictates that men and wom­en should do everything in their power to think proactive and preventative when it comes to their reproductive health, a recent study conducted by the U.S. Preventative Services Task Force made headlines with a hefty claim that blood tests intended to spot prostate cancer could also have unexpected side effects and that, perhaps, the tests may not be as necessary as once believed.

The task force's final guideline, published in late May, concludes that there's little if any evidence that prostate-specific antigen (PSA) testing saves lives. The findings also suggest the tests can bring about impotence, incontinence, heart attacks and occasionally even death from treatment of tiny tumors that never would have been fatal.

What makes it all the more controversial is the implied ­suggestion that healthy men shouldn't get routine prostate cancer screenings, no matter how old they are.

The guideline is not a mandate, but a suggestion that men who want a PSA test still can get one, but only after the doctor explains the uncertainties. However, several physicians are already speaking out to debunk the findings, saying that the prospect of making screenings unavailable would ultimately do more harm than help.

Some even suggest that the best way to address the issues the study raises is for doctors and patients to become more educated about what the screening entails, as well as the ways men can be affected by prostate cancer.

The American Association of Clinical Urologists and American Urological Association "are vigorously opposed to a blanket recommendation against screen­ing," explains Dr. Alan Wein, a urologist at the Hospital of the University of Pennsylvania.

"On a personal basis, I am against the findings and the D rating they assigned against PSA blood tests as well," Wein adds.

Indeed, "the terminology is inaccurate, as it should not be regarded as a 'screening,' but a program for early detection in certain individuals."

For years, men have undergone blood tests to track levels of the antigen produced by the prostate gland. If the test reveals elevated levels, it would indicate the presence of prostate cancer or a noncancerous condition such as prostatitis or an enlarged prostate. Last fall, this seemingly simple approach first came under attack when the task force proposed that the tests may be inconclusive at one end of the spectrum and possibly deadly on the other.

Dr. Eric M. Horwitz of Fox Chase Cancer Center points out that what makes the findings frustrating for him is that so much has been learned over the years in terms of diagnosing and treating cancers, that the notion that the task force suggests doctors just "throw our hands up in the air, and tell patients we should just wait to treat them once the cancer shows up" is shortsighted and irresponsible.

"While the panel talked about the side effects of treatment such as surgery and radiation, and these are very real, it is important to note that the side effects patients experience in 2012 are very different from those patients may have experienced 10, 20 and 30 years ago," says Horwitz.

"My problem is that their conclusions suggest that if some people don't need to be screened, nobody needs to be screened. Though I am not diminishing the difficulty of side effects, they are far less severe than they used to be thanks to improvements in the way treatments are administered."

Another criticism of the study is that the task force that made this sweeping recommendation did not include actual urologists, according to Dr. Leonard Gomella, chairman of urology at Thomas Jefferson University. He is concerned that the findings would create a slippery slope that would lead to removing access to the PSA blood tests, which, in turn, he fears, would throw back the clock 25 years.

"When I was a resident in the 1980s, 70 to 80 percent of men who walked through the door" were afflicted "with incurable metastatic prostate cancer," Gomella observes. "Because of these PSA blood tests, this statistic rarely happens" today.

Indeed, adds the Jefferson urologist chair, "the screenings on the whole do a lot of good things for us. It allows us to find the cancers earlier, and find cancers that do not involve the lymph nodes.

"The problem is that the pendulum has swung too far with early detection, so you are picking up signals for cancers that are so minimal they will not harm a patient in their lifetimes."

Gomella further suggests that the controversy also underscores the need for more awareness, money and education. This is, he says, in light of the fact that an estimated 30,000 men die from prostate cancer every year, while other men with less-threatening variances of the disease are not receiving correct advice or guidance from their doctors, which in turn would be worsened without the benchmarks established by PSA blood tests.

"My strong personal opinion is that it is not the screening that is the problem but the over­treatment of clinically un­im­portant cancer in this country," continues Gomella. "The irony about prostate cancer is that if they live long enough, all men will develop spots of pros­tate cancer," which are not deadly.

"With these clinically unimportant cancers, we are subjecting men to treatment to a type of cancer that would not harm them if untreated, along with the technical complications that go along with the treatments."

Horwitz, meanwhile, believes that the medical establishment needs to better pinpoint who would benefit from screenings and who would not, and screen the people who need it most. Doctors should consider the person's age and health, he says.

While prostate cancer for some men can be deadly if not properly spotted and treated, the panel's recommendation to consider making tests unavailable is the kind of thinking that harks back to men's health issues from the 1960s, '70s and '80s, when screening did not exist as it does today.

Wein points out that thanks to things like the PSA blood tests, urologists see far fewer cases of advanced prostate cancers.