If you are a man, age 50 and over, and find all of the information you are hearing about prostate cancer just plain confusing, do not feel alone. Because you are not the one with the problem. In no small part, the experts you rely on to provide you with clear, concise medical information and direction have not been in your corner for some time.
That’s not necessarily the experts’ or the doctors’ fault. There is so much confusing research and commentary about prostate cancer screening that someday someone will write a historical book on the subject. It may not be a best seller, but it will reinforce the fact that you have not taken leave of your senses when it comes time to make a decision about whether or not to get screened for prostate cancer.
An article this week in the Archives of Internal Medicine didn’t do much to clear the clutter. It certainly made the headlines, and the message delivered by our media friends was that prostate cancer screening is not effective.
Basically, the authors looked at medical records of men treated in VA Hospitals who had been diagnosed with prostate cancer between 1991 and 1995. Then, they picked other men at random who had not been diagnosed with the disease to compare to the men with cancer. They found 501 patients with prostate cancer, and had records reviewed from another 501 men without prostate cancer, who are what we call “matched controls.”
Then, the authors looked to find the number of men in each group who had been screened for prostate cancer with the well-known PSA test.
As you can imagine from the press coverage, the study did not show a benefit for screening. Essentially whether or not a man was screened for prostate cancer made no difference in the rate of death.
The study itself was well done, and the methods are complex and difficult to understand for both laypeople and professionals alike. But, I’m not certain that it answers the question about whether or not prostate cancer screening works at saving lives.
A little historical perspective about the state of the art of PSA testing around the time the researchers analyzed may be in order.
I was a primary care physician in the late 1980s and early 1990s. I recall that PSA was new at that time, and we really didn’t know much about it. We certainly didn’t understand the nuances of the test, and we didn’t understand that any upward change in the test was an indicator for follow-up, even if it was below the “normal” threshold. Our ultrasounds and biopsies weren’t as well perfected as they are now, and frequently we referred a patient with a slightly elevated PSA and no biopsy was done. Instead, we were told to get the PSA again in several weeks or several months. The tests themselves weren’t perfect, and using a different lab kit could result in a different number.
I could go on, but I think you can get the idea: we know more now than we did then, and “then” was the time frame when this study was done.
The bottom line is that there are too many variables in practice and understanding which existed at that time for me to have much confidence in the results of this study today, no matter the quality of the work that was done by the researchers.
So the arguments and the debates will go on. The sad part is that there is also confusion among the major organizations that make recommendations to men about whether or not they should be screened.
As noted in the article and the editorial which appeared in the same issue of the journal, one respected medical organization says the evidence is not sufficient to recommend routine screening for prostate cancer. Another says that it should be “offered” to men, but that organization (which is mine, by the way) says that offering doesn’t mean endorsement of the test, and that it is important men be educated about the benefits and risks of the test so they can make an informed decision. Yet another organization recommends the test for men at average risk age 50 and older.
It is this lack of clarity that is really a problem for everyone who is trying to decide what to do.
In addition, the rate of death from prostate cancer has been declining. But although some advocates say this is due to increased screening for prostate cancer, others say it is due to better treatment. What isn’t widely promoted as a point of view is that the rates of prostate cancer are also decreasing in other developed countries that do not have a widespread screening availability. And, according to the editorial, even here in the
This is no idle discussion. There are potential benefits from prostate cancer screening, but there are also significant drawbacks.
The PSA test, for example, is more frequently abnormal because of prostate enlargement than from cancer. That means a lot of men have biopsies and develop fear of cancer, when in fact the only problem they have is typical age related benign prostate enlargement.
Also, the treatment for prostate cancer may not be exactly a walk in the park, with serious side effects from surgery and also from radiation therapy, both accepted treatments for this disease. And, many men with prostate cancer are treated when we know that the disease (which becomes almost universal as men age and live long enough) would never cause them a problem during their lifetimes.
As noted in the editorial, there are some studies underway in the
Ultimately, what we need is a test that can indeed find prostate cancer early, and then another test that can distinguish whether or not a particular prostate cancer is one that needs to be treated, or even treated aggressively.
In the meantime, you are going to be left with confusion and lack of clarity. You can gather information, and you should be informed about the benefits and risks. You will make a decision whether or not you want to be tested. But what you won’t know is whether or not the decision to get the PSA test will really in truth save your life.
To that question, unfortunately, right now we just don’t have the answer.