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.)