Menstuff® has compiled the following information on the prostate testing controversy.
Is the PSA Test Still
Kaiser Permanente Recommends Against Prostate Screenings
The Prevalent View of ASCO, the American Cancer Society and many HMO's
The Danger in this View
Best Reason to Fight for More Research
Too Few Men With Low-Risk Prostate Cancers Get 'Watch and Wait' Approach
Dickinson students rock against prostate cancer at the first annual Blue Ribbon Bash
Omega-3 Fatty Acids Lead to Increased Risk of Prostate Cancer?
A New Treatment for Prostate Cancer
Protect Production of Medical Isotopes for Cancer Treatment
Older Prostate Cancer Patients May Face Age Bias
The Light Side
PCAW Press Release
Is the PSA Test Still Worthwhile?
Since the introduction of the PSA test, cases of advanced prostate cancer at the time of diagnosis have fallen 75 percent. Sounds like a success story, right? So why are so many doctors against it? We're teaming up with the Cleveland Clinic on their men's health campaign, #MENtionIt - here's what men need to know.
What to Know About the Prostate Cancer Screening Tool
When the prostate-specific antigen (PSA) blood test was approved in 1994 as a screening tool for the early detection of prostate cancer, it was hailed as a medical breakthrough that would save countless lives.
Before then, the lack of a systematic detection method had meant that prostate cancer often wasnt diagnosed until it had spread to other parts of the body, greatly increasing the likelihood it would be fatal.
In every year since the PSA tests introduction, the rate of prostate cancer deaths has declined, and cases of advanced prostate cancer at the time of diagnosis have fallen by 75 percent.
Confusion and Controversy
Sounds like a success story, right?
But barely a generation later, the PSA test is the subject of much confusion and controversy. It has earned a failing grade from an expert medical review panel that recommended against its routine use, and it seems to have fallen out of favor among many physicians and patients.
That has happened in large part because PSA finds too many low-grade cancers that are not destined to be harmful, needlessly exposing many men to the worry, cost, and potential complications of cancer treatment.
How did we get here, and what role, if any, does PSA have in prostate cancer screening? Is the test still worthwhile?
The short answer to that last question is yes.
The PSA test can provide valuable information when its used properly.
While I and other urologists share the concerns about overtreating non-lethal prostate cancers, many of us think the criticisms of the PSA test have been overstated.
When used in a rational way, the test still has value. To understand what I mean, lets back up a bit and examine what led to our current situation.
First, its important to know that not all prostate cancers are the same.
Many tumors grow very slowly or not at all, and cause little or no symptoms. These kinds of tumors are called indolent.
Since prostate cancer mainly occurs in older menthe average age at diagnosis is 66and since treatment with surgery and radiation can have unwanted side effects, such as impotence or incontinence, the logical thing to do in these slow-growing cases is just to keep an eye on things. The medical term for this is active surveillance, which means periodic checkups and re-evaluation of the cancers aggressiveness.
Nearly 100 percent of patients whose cancer has not spread outside of their prostate live at least five years after diagnosis. Put another way, the time it would take for an indolent prostate tumor to progress and cause harm in these patients, if it ever does, is often longer than their remaining lifespan. (Editor: The numbers don't add up. The average life span for a U.S. male is 76 years. If the average age of diagnoisi is 66 and they live an average of 5 years after diagnosis, what caused men with prostate cancer to lose an additional 5 years of life?)
Other prostate cancers, however, are aggressive, fast-growing, and potentially fatal.
They require timely treatment. The earlier theyre detected, the better the odds of success.
Patients whose cancer is still relatively contained to their prostate and nearby tissue when diagnosed are almost certain to be alive in five years. But those whose prostate cancer has spread to distant lymph nodes, bones, or other organs have a dismal 29 percent five-year survival rate.
So you can see why early detection is important. But its only half the battle. Being able to predict the course of a patients prostate cancerknowing whether its the slow-growing, no-action-required kind, the aggressive, fast-spreading kind, or something in-betweenalso is crucial.
Improving the Finger Test (Editor: Somewhat misleading title. This says nothing about improving the finger test. It speaks to adding other diagnostic tools)
For most of the 20th century, the only prostate cancer screening tool doctors had was their lubricated, rubber-gloved index fingerthe dreaded digital rectal exam, or DRE.
Probing the organ for signs of enlargement or lumps gave a hint of whether a tumor was present. But it wasnt definitive, it certainly wasnt comfortable, and it couldnt provide any information about the cancers likely course. A surgical tissue biopsy and other follow-up tests were used for that determination.
As you can imagine, by the time a prostate tumor was large enough to be felt, it probably was fairly advanced, which meant it likely wasnt curable. The DRE was hardly an ideal early-detection method.
Then along came the PSA test. It detects the amount of a protein called the prostate-specific antigen thats produced by the cells of the prostate gland and circulates in the bloodstream.
The PSA level often is elevated in men with prostate cancer. The combination of the DRE and PSA test dramatically improved our ability to catch prostate tumors early.
PSAs Drawbacks Include Overdiagnosis
But the PSA test has a number of downsides, too.
First, other things besides prostate cancer can cause PSA levels to risenon-cancerous conditions such as prostate inflammation or the enlargement that happens with aging, for example. Second, theres no clear-cut normal PSA level. Many men with a high PSA result dont actually have prostate cancer, while some with low levels do. Third, the tests false-positive rates are high, causing needless worry in patients who dont actually have cancer. And finally, the PSA test cant distinguish between slow-growing cancers that dont need treatment and aggressive ones that do. (Editor: Other issues that distort results include
The widespread adoption of the PSA test beginning in the 1990s meant that lots more prostate cancers were detected at an early stage, before any symptomsa good thing for those needing immediate treatment, but not so good for those who didnt.
Prostate cancer survival rates increased, but so did the number of men with indolent tumors who unnecessarily underwent biopsies, had their prostate surgically removed, endured radiation therapy, and experienced the unfortunate side effects of those procedures.
Two large studies estimated the rate of prostate cancer overdiagnosis (the detection of a non-life-threatening tumor) due to PSA test results at between 17 and 50 percent.
And researchers found no clear evidence that regular PSA screening was directly responsible for a significant drop in cancer deaths. (The decline in prostate cancer death rates I mentioned in the second paragraph of this article could be due to a number of other factors, including improved treatments.)
Groups Disagree About Testing
So what doctors and patients were left to wrestle with was a test that seemed like a mixed bag: It detected lots of early-stage cancers, whether they needed treatment or not, and it didnt seem to be making much of a dent by itself in the number of prostate cancer deaths.
By 2008, the U.S. Preventive Services Task Force, an influential panel of experts in primary care and preventive medicine (but not urology or cancer), (Editor: This is ludicris, using untrained doctors to make judgements about testing for a desease they have little or no expertise in. Like asking the guy at the tire shop to critigue a malfunction in the cars computer system. My sense is that HMOs and insurance companies had a lot to do to mislead the public, as the American Heart Association did for years about saturated fat, since a PSA test was covered in many insurance plans) recommended that men 75 and older not underg.o PSA screening. In 2012, the panel broadened its advisory against PSA testing to include men of all ages, saying the tests harm outweighed its benefits.
Several other medical groups disagreed, arguing that younger patients with potentially curable prostate cancers, and those at increased risk (such as men of African descent and those with a family history of prostate cancer) would still gain from regular PSA testing. They warned that a decline in screening might cause a return to the days when prostate cancer wasnt detected until its advanced, incurable stage.
Without agreed-upon guidelines, doctors and patients were caught in the middle. Doctors often left the testing decision to their patients. PSA screening rates did fall, and so did the diagnoses of early-stage (and presumably inconsequential) prostate cancers.
Worryingly, though, a recent study reported that the number of newly diagnosed cases of advanced prostate cancer has sharply risen since 2007. While theres been some criticism of the studys methods, its not a stretch to think that less prostate cancer screening means more cases of important and treatable cancers wont be caught until theyve spread.
A Rational Approach to the PSA Test
So in this confusing environment, whats a patient supposed to do? Ideally, someone would invent a smarter screening testone that not only reliably identifies early-stage prostate cancer but can accurately predict its course, clarifying whether and how to treat.
Fortunately, there are improved screening tests in the pipeline, as well as other developments that should help improve diagnostic accuracy. (Editor: Actually, PSA3, Free PSA testing for free radicals, and Color Doplar have been around for at least 10 years and the later is so much more accurate than an ultrasound for detecting prostate cancer and its location so that when a biopsy is run, using it, most cases report cancer in 100% of the needles.)
Meanwhile, heres the approach to PSA testing I recommend and that I use with my patients:
Get an initial benchmark PSA at age 50. Your doctor can order the test and discuss the results with you. If the test result, combined with your medical history and other clinical information indicates a low risk of developing prostate cancer, follow-up PSA testing should be repeated every five years.
If your initial PSA test and medical information at age 50 show an elevated risk of prostate cancer but you have no symptoms, (Editor: What symptoms are there prior to having advanced prostate cancer?) you should have a screening every other year using one of the smarter blood tests I mentioned earlier (the 4Kscore or Prostate Health Index tests), and possibly an MRI scan of the prostate. Talk with your doctor about these options. Based on the follow-up results from these tests, you and your doctor can decide together what additional steps, if any, are needed.
If by the age of 60 your PSA level is below 2 nanograms per milliliter, your chance of developing aggressive prostate cancer in the remainder of life is very small1 or 2 percent. At that point, its safe to repeat the PSA test much less often than every five years, or stop testing altogether.
With this common-sense approach, we can still catch high-grade cancers that need treatment while also reducing the likelihood of diagnosing low-grade tumors that arent harmful but would cause needless worry and treatment.
Dr. Klein is Chairman of Cleveland Clinics Glickman Urological & Kidney Institute, the nations No. 2 urology program as ranked by U.S. News & World Report.
Barocas DA, Mallin K, Graves AJ, et al. Effect of the USPSTF Grade D Recommendation against Screening for Prostate Cancer on Incident Prostate Cancer Diagnoses in the United States. J Urol. 2015 Dec;194(6):1587-93.
Barry MJ, Nelson JB. Opposing Views: Patients Present with More Advanced Prostate Cancer since the USPSTF Screening Recommendations. J Urol. 2015 Dec;194(6):1534-6.
Catalona WJ, D'Amico AV, Fitzgibbons WF, et al. What the U.S. Preventive Services Task Force missed in its prostate cancer screening recommendation. Ann Intern Med. 2012 Jul 17;157(2):137-8.
Moyer VA, LeFevre ML, Siu AL, et al. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jul 17;157(2):120-34.
Surveillance, Epidemiology, and End Results (SEER) Program Stat Fact Sheets: Prostate Cancer. National Cancer Institute. Accessed at http://seer.cancer.gov/statfacts/html/prost.html
Kaiser Permanente Recommends Against Prostate Screenings
* The Reasons Kaiser gives for not having a PSA test:
Many other expert organizations like the U.S. Preventive Services
Task Force, the National Cancer Institute and the Canadian Task Force
on Periodic Health Exams do not recommend PSA testing. Althought
the American Cancer Society recomends prostate cancer screening and
wants to increase public awaerness, the more frequent testing that
they recommend has not been shown to prevent prostate cancer deaths.
(Actually, the American Cancer Society no longer recommends testing,
The Prevalant View of ASCO, the American
Cancer Society and many HMO's
Unlike other cancers, prostate cancer grows very slowly in many (not all) men, so slowly that they would not threaten the life of the patient if not treated. So detecting cancer may subject some men to surgery and other treatments that might not ever be needed. Since prostate cancer treatments have significant side effects, treating it unnecessarily can seriously affect a mans quality of life.
Until there is more complete research to evaluate, ASCO does not yet have an official statement about prostate cancer screening, or recommendations for men on when they should start getting tested for prostate cancer. Patients should discuss their situation with their doctor and work together to make a decision.
The Danger in this
Prostate cancer is the most commonly diagnosed malignancy in American men. It is curable if diagnosed early. Early detection is the key.
About 30,000 men will die from it this year alone. Men over 45 don't need another excuse to avoid taking care of their health.
But the argument against the use of the prostate specific antigen blood test for detecting prostate cancer has provided that excuse -- pitting public health officials and primary care physicians, who claim there is no evidence of PSA success beyond a reasonable doubt, against many urologists who ask why a 27 percent decline in prostate cancer mortalities in the past five years isn't evidence enough.
Despite American Cancer Society and American Urological Association guidelines that encourage doctors to offer a PSA test and a digital rectal exam while discussing the risks of the disease, too many doctors lean toward discouraging the test, focusing on misplaced convictions that the test discovers insignificant tumors and that it doesn't save lives.
Physicians who have deferred or waffled on PSA testing are losing their licenses and seeing their malpractice insurance carriers pay out millions of dollars to bereaved families.
In a November 2001 wrongful death suit, a widow was awarded $3 million in a case in which the doctor in question "did not tell the patient about [the high PSA level] or recommend further testing or follow up visits."
A study at Long Beach Community Cancer Center of 48 such prostate cancer malpractice cases determined that, of the 22 awards totaling over $8.4 million, roughly $7.5 million "could have been avoided if PSA screening and diagnostic guidelines . . . had been followed."
These cases have become legal benchmarks as the PSA debate has moved from the doctor's office into the courthouse. They should come as a warning to science and public health policy officials across the country: If you continue to delay a decision on PSA, lawyers and lawmakers will make it for you.
Urologists will tell you that, despite imperfections, the PSA test has changed the prostate cancer diagnostic landscape. Before it, nearly three out of four men diagnosed with the disease were in the late stages -- when prostate cancer is neither readily treatable nor curable. The advent of screening has inverted that statistic, giving men a fighting chance. Regional studies support that early detection reduces mortality. One study in Austria shows that prostate cancer mortalities were markedly reduced with widespread PSA screening.
Even though newer blood tests help clarify the likelihood of cancer when PSA is abnormal, we still need more research to determine better models for early detection. But should we doom the thousands of men who could die waiting up to 14 years for the results of a randomized trial to determine "perfect intelligence" on the PSA? With so many lives in the balance, how much evidence do we need to convince us that prostate cancer is our enemy, not the test that so often detects it in time to permit a cure?
Men over the age of 50 -- and even younger if they are at higher
risk of prostate cancer (African Americans and men with family
histories of the disease) should "get on with it." Set aside the
excuses and resolve to be tested every year.
Source: Carl Frankel, an advocate for the National Prostate Cancer Coalition, is retired general counsel for the United Steel Workers of America and a prostate cancer survivor. www.post-gazette.com/healthscience/20020611hprostate4.asp
Best Reason to Fight for More Research
The major reason all of these major organizations that deal with cancer are not recommending testing is because, unlike breast cancer, they say they haven't found anything that improves or extends a man's life if he gets prostate cancer so, basically, just let it grow. With almost five-times more research spending per death, plus untold millions on awareness, breast cancer cures are seeing great results. At the rate men bought Viagra, you've got to believe they would spend a lot if there was something that could stop prostate cancer without becoming impotent or incontinent. The difference is that women have raised the banners. Have spend their personal time and money to make things happen, have purhcased millions of Breast Cancer Awareness Stamps, have made a difference. Unlike women, few men have done any of those things, and while the U.S. Postal Service did creat a Prostate Cancer Awareness stamp, over 50 million of the 78 million stamps sit un-purchased. Will anyone wake up before you get prostate cancer to find a way that helps men live out those final years happier and healthier? Will you?
Note: Spending in 1997 on research looked something like this:
Breast Cancer $12,800/death, prostate cancer $2,700/death.)
Male Cancer on Increase
Men "Unwilling" to Discuss Cancer
New prostate cancer
test advice overturns dogma
They may not listen. After all, the vast majority of men over 50 already get tested.
The idea that finding cancer early can harm instead of help is a hard one to understand. But it's at the heart of a government panel's draft recommendation that those PSA blood tests should no longer be part of routine screening for healthy men.
The U.S. Preventive Services Task Force examined all the evidence and found little if any reduction in deaths from routine PSA screening. But it did conclude that too many men are diagnosed with tumors that never would have killed them and suffer serious side effects from resulting treatment.
That recommendation isn't final it's a draft open for public comment. But it goes a step further than several major cancer groups including the American Cancer Society, which urges that men be told the pros and cons and decide for themselves.
The new advice is sure to be hugely controversial. Already some doctors are rejecting it.
"We all agree that we've got to do a better job of figuring out who would benefit from PSA screening. But a blanket statement of just doing away with it altogether ... seems over-aggressive and irresponsible," said Dr. Scott Eggener, a prostate cancer specialist at the University of Chicago.
In the exam room, explaining the flaws in PSA testing has long been difficult.
"Men have been confused about this for a very long time, not just men patients but men doctors," said Dr. Yul Ejnes, a Cranston, R.I., internal medicine specialist who chairs the American College of Physicians' board of regents.
He turned down his own physician's offer of a PSA test after personally reviewing the research.
"There's this dogma ... that early detection saves lives. It's not necessarily true for all cancers," Ejnes said.
That's an emotional shift, as the American Cancer Society's Dr. Len Lichtenfeld voiced on his blog on Friday.
"We have invested over 20 years of belief that PSA testing works. ... And here we are all of these years later, and we don't know for sure," Lichtenfeld wrote. "We have been poked and probed, we have been operated on by doctors and robots, we have been radiated with fancy machines, we have spent literally billions of dollars. And what do we have? A mess of false hope?"
Too much PSA, or prostate-specific antigen, in the blood only sometimes signals prostate cancer is brewing. It also can mean a benign enlarged prostate or an infection. In fact, most men who undergo a biopsy for an abnormal PSA test don't turn out to have prostate cancer.
Screening often detects small tumors that will prove too slow-growing to be deadly by one estimate, in 2 of every 5 men whose cancer is caught through a PSA test. But there's no way to tell in advance who needs treatment.
"If we had a test that could distinguish between a cancer that was going to be aggressive and a cancer that was not, that would be fabulous," said Dr. Virginia Moyer of the Baylor College of Medicine, who chairs the task force, an independent expert group that reviews medical evidence for the government.
About 1 in 6 U.S. men will be diagnosed with prostate cancer at some point in their life. Yet the cancer society notes that in Western European countries where screening isn't common, 1 in 10 men are diagnosed and the risk of death in both places is the same. In the U.S., about 217,000 men are diagnosed with prostate cancer each year, and 32,000 die.
Why not screen in case there's a mortality benefit that studies have yet to tease out? The task force outlined the problem with that:
Among the questions sure to be raised during the public comment period are how doctors should advise men with prostate cancer in the family or black men, who are at increased risk.
PSA testing also is used to examine men with prostate symptoms, and to check men who already have had prostate cancer. The new recommendation doesn't affect those uses.
Congress requires that Medicare cover PSA tests, at a cost of $41 million in 2009. Other insurers follow Medicare's lead, especially in light of conflicting recommendations.
Nor does the new recommendation mean that men who want a PSA test can't have one. If the rule is adopted something the government will review once the task force hears comments and finalizes its guidance it would just advise against doctors pushing it routinely.
"The truth is that like so many things in medicine, there's no one-size-fits-all," said Dr. Michael Barry of Massachusetts General Hospital who heads the Foundation for Informed Medical Decision-Making that backs ways to help patients make their own choices.
(Editor's Note: The question I have is who's going to volunteer to tell the 32,000 men who die each year not to get tested because we might have to do something that will make you incontenent.)
PSA decision guide: http://bit.ly/cXq1QE
Too Few Men With Low-Risk Prostate Cancers Get
'Watch and Wait' Approach
Study finds 12 percent or fewer getting active surveillance.
A wide majority of U.S. men with low-risk prostate cancer are being treated for the disease even though "active surveillance" is an option, a new report finds.
Active surveillance -- or watchful waiting -- is the careful monitoring of prostate cancer for progression of the cancer that would indicate a need for treatment. Men in the Northeast and on the West Coast were especially likely to have active surveillance rather than cancer treatment, potentially sparing them from complications associated with treatment.
The study data was collected in 2010 and 2011, and a lot has changed since that time in regard to the popularity of active surveillance, experts noted.
Active surveillance is "gaining acceptance among urologists and patients," said study co-author Dr. Hui Zhu, chief of urology at the Louis Stokes Cleveland VA Medical Center in Ohio.
"Age-appropriate men should discuss the risks and benefits of screening with their physicians, and men with newly diagnosed localized prostate cancer should ask their physicians whether active surveillance is a good option for them," he added.
There's been controversy for years about diagnosing and treating prostate cancer. Tumors considered to be low-risk may never spread, but men have often been treated anyway. But, those treatments aren't without risk. Prostate cancer treatments can cause serious and lasting side effects, such as incontinence and erectile dysfunction, according to the American Cancer Society.
In 2011, the U.S. Preventive Services Task Force discouraged the use of routine prostate cancer testing. One reason why was because of the odds that low-risk tumors would be treated. But, despite that recommendation, many doctors continue ordering the prostate-specific antigen (PSA) tests. Supporters of the test suggest that if the PSA leads to an overdiagnosis of low-risk prostate cancers, that problem can be countered with active surveillance, the study authors noted.
The new report examines a national database that includes about 70 percent of cancer cases in the country.
Of nearly 190,000 mean diagnosed with prostate cancer, between 11 percent and 40 percent would be considered low-risk enough to be eligible for watch-and-wait approach. (There isn't a consensus about which patients should consider this strategy, and the report looks at different cut-off points.) Of those men, just 7 percent to 12 percent had active surveillance, the study revealed.
Older men -- those over 60 -- were more likely to have active surveillance. Men without insurance were also more likely to have active surveillance, the study said.
The researchers found that watchful waiting was most common on the West Coast and in the Northeast. The states with the lowest levels -- under 5 percent -- were Alabama, Mississippi, Tennessee and Kentucky.
Dr. Stephen Freedland, a urologist and director of the Center for Integrated Research in Cancer and Lifestyle at Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute in Los Angeles, pointed out that the report's data is outdated. The situation has "changed dramatically" over the past few years, with early research suggesting that many more men are choosing the surveillance option.
Before, he said, doctors chose treatment instead of monitoring because they weren't comfortable with watchful waiting and "didn't fully appreciate how well the patients do; how safe it is to do that."
He said it's rare for patients to simply never come back after being diagnosed.
Also, he said, "there was no imperative, no push to do it. It's a counterintuitive thing to say 'You have cancer, but I'm not going to do anything.'"
So, where does that leave men with low-risk prostate cancers?
"Prostate cancer, even the lethal form, is highly treatable when it is detected at an early stage through the use of screening," Zhu said.
"Men aged 55 to 69 years who are considering being screened for prostate cancer should have a discussion with their physicians which involves weighing the benefits of preventing death from prostate cancer against the known potential harms associated with screening and treatment," Zhu added.
The report was published online June 29, 2015 in the journal
JAMA Internal Medicine.
Note: We've asked the author
(7/11/15) wha happened that 30,000 men are missed each year from
treated that, as the article claimed, if caught early enough is an
easy cure. Why did they die? No answer yet. The author may be getting
paid by HMOs to encourage men not to be
"You cannot sit back and do nothing because you'll never have perfect intelligence on the enemy...Get on with it." General Norman Schwarzkopf said after he was diagnosed with prostate cancer