Former Minnesota-based health writer Jim Thornton (now living in Pittsburgh) has written a great article for Men’s Health on the dilemma men face about whether to undergo PSA (prostate-specific antigen) screening for the early detection of prostate cancer.
Thornton, who is well known for his first-person approach to exploring health topics (he won a coveted National Magazine Award in 1998), opens the article by talking about his father’s diagnosis and treatment of prostate cancer, which occurred six years before his father died — not of prostate cancer — at age 81.
“At the time,” writes Thornton, “I couldn’t help but wonder what would have happened if he’d never gone for a PSA test, that seemingly sensible first domino that triggered multiple biopsies and ultimately the removal of his prostate. Might he have died sooner and more painfully? Or might his final years have proved happier ones had he been able to enjoy sex and live in blissful ignorance about a cancer that never caused a single symptom? The urologist, for his part, was adamant that he had helped my father dodge a bullet. I wondered if it was a Nerf bullet.”
Evaluating the evidence
Thornton then takes the reader through his own journey of research into the arguments for and against prostate cancer screening. He begins with a recap of the decision by the United States Preventive Services Task Force (USPSTF), first announced in the fall of 2011, to recommend against preventive PSA screening. This independent group of experts had meticulously studied the medical evidence and determined it overwhelmingly showed that the test’s harms outweigh its benefits.
Thornton then discusses the angry pushback against those recommendations, led by the American Urological Association and the patient-advocacy group Zero: The Project to End Prostate Cancer (which Thornton points out is funded by drug and medical-device manufacturers).
“Practicing urologists remain nearly unanimous in concluding that the Task Force’s findings are bunk,” writes Thornton. “On the other hand, clinical researchers — one of the most notable being Richard Ablin, Ph.D., a professor of pathology at the University of Arizona and the researcher credited with identifying and naming PSA in the first place — tend to support the group’s conclusions. ‘I’m not suggesting that prostate cancer be ignored,’ he says, ‘but PSA just doesn’t work as a screening test. It’s little better than a flip of the coin.’ In the zeal to save men from prostate cancer at the exclusion of all other concerns, Ablin believes, doctors have forgotten their overriding obligation: Primum non nocere: First, do no harm. ‘PSA screening,’ Ablin says, ‘has resulted in a public health catastrophe that’s been nothing short of criminal.’”
Thornton notes that urologists practice what they preach: One survey found that 97 of male urologists report that they themselves intend to begin having PSA screenings at age 50 (compared to 72 percent of male internists).
As Dr. Otis Brawley, chief medical officer for the American Cancer Society and a long-time critic of universal preventive PSA screenings, told Thornton: “It seems that most urologists have come to believe their own stories, while internists are more skeptical.”
Strong financial incentives
Thornton wonders, however, if “privately, some may also want to avoid killing a golden goose”:
At $1,000 or more per biopsy, the cost to U.S. health care for prostate biopsies alone is estimated to run into the billions each year. Whenever cancer is found, expenses escalate even more ferociously: Surgery and hospitalization for a radical prostatectomy, for example, can easily top $13,000 — more for men who opt for robot-assisted prostatectomies, today’s sexy new “nerve-sparing” variation on open surgery.
External beam radiation is in the same ballpark. At $200 million proton-beam centers, a course of proton therapy — another trendy new fix that claims to target the tumor and little of the surrounding tissue — is pricier still, costing more than $30,000 per patient. A 2011 study in the Journal of Urology suggests that it costs $5.2 million to prevent a single death from prostate cancer detected via PSA screening.
That’s a lot of money on the table. So perhaps it’s not surprising that even though there’s little evidence proving which treatment is best, most urologists, many of whom perform radical prostatectomies, recommend surgery over radiation — despite research suggesting that surgery more often result in [erectile dysfunction] and incontinence.
Thornton concludes by acknowledging that he’s decided not to undergo preventive PSA screening — a decision he says he’s “made peace with … even though it contains the seeds of possible regret.”
Again, the article is a great read. You’ll find it online at the Men’s Health website. (Full disclosure: Thornton is a friend of mine.)
I agree
and have made the same decision.
The data say that overall you’re more likely to be harmed by getting the test than by skipping it.
One can’t ignore the fact that the people advocating the test have a financial stake in it. That doesn’t mean that they’re deliberately ignoring the data to make an extra buck; just that their judgement is affected by their personal stake, just as my judgement is affected by mine.
Great article
Thanks for writing about Jim’s fine article. He gets all the smartest people into his pieces and then also tells a moving personal story about his family. Another great read on the subject is Should I Be Tested For Cancer by Gilbert Welch, who Jim interviews in the piece if I’m not mistaken. Breast and prostate screening are bookends of an over-treatment culture, brought to us by the medical industrial complex, that has been so terribly expensive in our time, exacting a steep monetary and emotional cost.
Thornton piece should have considered broader options
It is incorrect for the Thornton article to say that the position that the benefits of PSA screening outweigh the costs rests on rejecting the results of both the European and U.S. screening experiments. Rather, it rests on believing the results of the European experiment, and not the results of the U.S. experiment.
The European experiment did find a clear benefit of PSA screening and the resulting subsequent treatment in reducing prostate cancer deaths. Reasonable simulations using these results suggest that the ratio of harms to benefits are such that many men would want to be screened.
For example, using the European study’s results, Gulati, Gore, and Etzioni, in a recent paper (Feb. 2013) in the Annals of Internal Medicine, find that various screening strategies result in from 3 to 7 additional men being treated for prostate cancer to every 1 man whose prostate cancer death is averted. If about half of the men treated suffer from impotence or incontinence, then the ratio of men harmed to life saved is somewhere between 1.5 to 1 and 3.5 to 1. That’s a difficult tradeoff. On the one hand, more men are harmed than benefit. On the other hand, many men would rather be alive and impotent or incontinent than dead. I think reasonable people may come to different conclusions about whether or not they want to be screened AND agree to treatment if the screening reveals prostate cancer.
On the other hand, the U.S. prostate cancer screening experiment found no benefits of screening. But the biggest problem with this study is that over half of the control group was also screened. This reduced the statistical power of the experiment, and meant that this experiment perhaps reveals more whether more or less screening makes a difference, not whether screening makes a difference.
The notion of “first do no harm” is not really applicable here, because no matter what you do , you do harm. If you don’t screen, the European study suggests that prostate cancer deaths will increase by 20%. In the Gulati, Gore, and Etzioni simulations, eliminating screening increases prostate cancer deaths by from 0.4% to 0.8% of all men. On the other hand, if you do screen and then subsequently treat men for prostate cancer, more men will be impotent or incontinent. There are harms either way.
A middle position, which Gulati, Gore and Etzioni advocate, is to think about moderate screening strategies: only certain age ranges should be screened, and then not every year, and then you don’t need to biopsy at the lowest possible PSA levels that might be related to prostate cancer. Furthermore, as many doctors have advocated, if the biopsy reveals relatively low-grade prostate cancer, you can opt for active suveillance, and monitor the prostate cancer to see if it shows any sign of getting worse. A moderate screening strategy with use of active surveilllance in more cases will reduce prostate cancer deaths compared to no screening by almost as much as more aggressive screening and treatment strategies, but will have significantly fewer men treated for prostate cancer and therefore fewer harms. I think this article should have highlighted that there are many different screening and treatment options for prostate cancer. It’s not an all or nothing decision.
I am very sorry for the harms suffered by Mr. Thornton’s father. Given his age, it is likely that screening has fewer benefits relative to harms than for men in their 50s. And given his age, if his biopsy revealed a low-grade prostate cancer, one would have hoped that active surveillance rather than treatment would have been considered as a preferred option.