Editorial: If PSA test saves lives, averages don't matter
For men older than 50, a simple blood test to screen for prostate cancer is as much a part of annual physicals as weigh-ins and stethoscopes. The PSA test is painless, inexpensive and the only way to detect the disease — the most common male cancer — before symptoms turn up.
OPPOSING VIEW: PSA screening can lead to harm
Yet an influential commission charged with assessing medical treatments is recommending that routine screening be ended, to the furor of doctors, including the American Urological Association.
The commission, the U.S. Preventive Services Task Force, doesn't dispute that the test detects cancer. Instead, it argues, with a formidable arsenal of data, that the test leads to widespread over-treatment, which outweighs the benefits of early detection. Over the entire society, it says, there is no net gain and substantial damage to patients, ranging from needless worry, to impotence and incontinence, to death.
And therein lies a dilemma for the older-than-50 male, for whom averages mean little.
If he isn't tested, he'll be spared the false positives the test commonly produces as well as treatment risk. On the other hand, if he has high-grade cancer, the disease might not be found until it has spread to other organs, which is fatal. The five-year survival rate for localized prostate cancer is 100%. Once the cancer reaches distant organs, the rate falls to 28.8%.
The panel's data make a compelling case that the overall societal benefit from widespread PSA screening is marginal, and it is not the first group to say so. In fact, the skeptics include the man who invented the PSA test. So in statistical terms, the diagnosis appears sound. But in tallying the damage, the commission makes some relatively small problems seem very big.
Yes, knowing you might have cancer is stressful, but it's better than not knowing. And yes, the biopsies that typically follow a rise in PSA can be painful, but for most patients they're not. As for the major complications — urinary incontinence and erectile dysfunction — they're usually temporary and highly treatable. They're also a lot better than being dead.
More troubling is the commission's solution.
It proposes eliminating the information that leads to over-treatment, rather than reforming the treatment itself. This is necessary, says the panel's chairman, Virginia Moyer, because once patients hear they have cancer, human nature drives them to demand aggressive action, necessary or not, and because engineering massive change in medical practices is a Herculean task.
She has a point, but ignorance is not bliss. It leaves the poor fellow with undetected high-grade cancer as collateral damage. The fact that his death might be statistically offset by the survival of someone who would have died from unneeded treatment is cold comfort.
It's important to note that the commission is not seeking to ban PSA testing. It just wants an end to routine screening. Doctors would still administer PSA tests when symptoms and risk factors warrant. Still, depriving people of information that empowers them to make choices is disturbing. Even more so because the panel's work has broader implications.
With the cost of American health care wildly out of control, the hunt is on to reduce unproductive treatments. The prostate recommendation, like the commission's equally controversial suggestion in 2009 to do fewer mammograms, is a measure of how difficult that discussion will be.
Meanwhile, at the risk of practicing medicine without a license, here's our suggestion for the 50-plus male: Get tested, then get smart. Information about prostate cancer and its treatment is readily available from the National Cancer Institute, major cancer centers and other sources.
Being left in the dark — whether by choice or medical fiat — is not a helpful option.