22 May 2012

Experts Warn Against PSA Testing

Story first appeared in USA Today.
Doctors should no longer offer the PSA prostate cancer screening test to healthy men because they're more likely to be harmed by the blood draw — and the chain of medical interventions that often follows — than be helped, according to government advisory panel's final report.

Even after studying more than 250,000 men for more than a decade, researchers have never found the PSA to save lives, according to the U.S. Preventive Services Task Force, a panel of doctors that advises the government on cancer screenings and other ways to avoid disease.

Yet the PSA can cause harm.

That's because the PSA, which measures a protein called prostate-specific antigen, often leads to unnecessary needle biopsies for men who don't actually have cancer. Even worse, those biopsies lead many men to be treated for slow-growing cancers that never needed to be found and that are basically harmless.

Because doctors today often can't tell a harmless tumor from an aggressive one, they end up treating most men with prostate cancer the same.

Treating harmless prostate tumors can't possibly help men, however. It only increases the odds of making them impotent or incontinent. Treatment can even be deadly: One in 200 men who have prostate surgery die shortly after the procedure.

The recommendation, first released as a draft in October, applies to healthy men of any age, although not for those who already have been diagnosed with prostate cancer.

The panel didn't consider cost in its deliberations. Federal legislation requires that Medicare must continue to pay for the PSA. Private insurers usually follow Medicare's example.

In the future, the hope is that doctors will simply stop mentioning the PSA when men come for office visits. If men ask for the test, or if doctors still want to offer the PSA, physicians should discuss both the risks and benefits of screening. Although the task force aims to help doctors by issuing recommendations, physicians aren't obligated to follow its recommendations. Men desperately need a better test. More than 28,000 men die of prostate cancer a year.

Unfortunately, there are no other better tests with which to replace the PSA, such as rectal exams, ultrasounds or variations on the PSA.

But the task force went too far in rejecting the PSA completely. Death rates from prostate cancer nationwide have dropped 30% to 50% since PSA testing became widespread in the early 1990s. In its recommendations, published in Monday's Annals of Internal Medicine, the task force said it's unlikely that screening alone could have reduced death rates so quickly. Some experts note that treatments also have improved.

Some experts don't want to go back to the "bad old days" before screening, when doctors found prostate cancer only after it had become incurable. And because many men are used to getting PSAs, some might not realize their doctors have stopped performing the tests.
A patient might presume they've had their PSA tested, then come back five or 10 years later with back pain, only to learn they have prostate cancer that's spread to their spine.

A 66 year old man had developed a life-threatening bloodstream infection called sepsis after his PSA results led to a needle biopsy, and he was hospitalized for three days. Though such infections are rare, the patient says one such experience was enough; he hasn't had a PSA since.

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