PROSTATE CANCER: PSA Screening and the Patient-Doctor Relationship

Peter Bretan, MD, FACS

In October 2011, the U.S. Preventive Services Task Force released draft recommendations against prostate-specific antigen (PSA) screening for prostate cancer, asserting that there is “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” The task force further discouraged use of the PSA test by giving it a Grade D rating.

I am a board-certified, fellowship-trained urologist and professor of urology. I have been treating men with diseases of the prostate, both benign and cancerous, for the past 26 years. Along with my specialty society, the American Urological Association (AUA), I strongly oppose the task force’s recommendations. I believe the task force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.

In 2009, the AUA issued a PSA Best Practice Statement finding that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.[1] Not all prostate cancers are life-threatening, and the decision to proceed to active treatment or use surveillance for a patient’s prostate cancer is one that men should discuss in detail with their urologists.

Following the release of the task force’s recommendations, AUA President Dr. Sushil Lacy released a statement urging men to speak with their physicians about the value of prostate cancer screening.[2] The AUA is also coordinating a sign-on letter for lawmakers to send collectively to U.S. Health and Human Services Secretary Kathleen Sebelius, urging her to reject the task force’s recommendations. In addition, the AUA is convening an expert panel that will submit formal comments to the task force.

Despite data from the National Cancer Institute showing decreasing mortality from prostate cancer since PSA testing began in the 1980s, the task force argues that the test can lead to harm. They don’t dispute that PSA testing detects cancer, but they do claim that the test leads to widespread overtreatment, which to them outweighs the benefits of early detection. By averaging data over the entire population, the task force concludes that there is no net gain from PSA testing and perhaps substantial damage to patients, ranging from needless worry, to impotence and incontinence, and even to death.

Therein lies the dilemma for the older-than-50 male for whom averages mean little. Without PSA testing, if a high-grade prostate cancer is present, the disease might not be found until it is fatal. Although the five-year survival rate for localized prostate cancer is 100%, once the cancer reaches distant organs, the rate falls to 29%.

In tallying the damage from PSA testing, the task force makes some relatively small problems seem very big. For example, they suggest that biopsies can be painful. In reality, the use of local anesthesia during biopsies makes pain an uncommon experience. Major complications after biopsies are rare. Even if prostate cancer is found and the patient elects to have the prostate surgically removed, the complications of urinary incontinence and erectile dysfunction are usually temporary and highly treatable. They’re also preferable to metastatic cancer and death.

As articulated by Cleveland Clinic urologist Dr. Andrew Stephenson, “None of us would dispute that there are harms with screening for prostate cancer, just as there are for screening for any other cancer, but the task force fails to acknowledge the benefits, which are clear.”[3] The PSA test is painless, inexpensive and the only way to detect prostate cancer—the most common male cancer—before symptoms turn up.

What disturbs me most about the task force is that they recommend against gathering the information that leads to overtreatment, rather than reforming the treatment itself. The chair of the task force, Virginia Moyer, claims that once patients hear they have cancer, human nature drives them to demand aggressive action, necessary or not. While she has a point, the use of ignorance to help protect patients is not bliss, nor a medical practice I can condone.

Failing to administer the PSA test would sacrifice patients with undetected high-grade cancer, unbeknownst to them. The fact that such patients’ death prevention might be statistically offset by someone who receives unneeded treatment seems to be a cold-hearted practice of pure bureaucracy and not the compassionate practice of medicine. Depriving people of information that empowers them to make choices is disturbing.

With the cost of American health care rising rapidly, the rationale to reduce unproductive treatments is well appreciated, but not at the expense of practicing ethical, transparent and compassionate medicine. The task force’s recommendation against PSA testing, like their equally controversial suggestion in 2009 to do fewer mammograms, is a measure of how cost needs to be addressed—but cost control should not come at the expense of informed consent with the patient.

I believe that men older than 50 should continue to receive the PSA test, then get balanced information about prostate cancer and its treatment. That puts decision making back to patients, in close consultation with their physicians. I have always advocated for my patients and defend the patient-doctor relationship as the backbone of medical practice. Physicians are messengers and educators for their patients, in the elucidation of the risks, complications and alternatives of all therapeutic options.

For many of my patients, I recommend no immediate therapy for low-volume, medium-grade prostate cancer. Can we all do better in this standard of care? Absolutely. Unfortunately, the task force implies that patients cannot make this decision because it is too emotionally laden, and that urologists are all going to push for interventional therapies that may be inappropriate or injurious to patient. This is simply not true. Academic urologists are constantly studying ways to fine-tune the selection of patients for specific therapies.

The task force’s recommendations would restrict the patient-doctor relationship by holding back the results of a simple test that has been shown to save lives, because “on the average” they see the benefits to society as “marginal.” Perfect is often the enemy of good, but in this case “doing nothing” is the enemy.

We improve our way of living with science, not with denial, which has never helped anyone. There isn’t an “average” cookie-cutter template that fits all patients. If there were, there would be no need for the practice of medicine, only algorithms and protocols. Recommending against a valuable and simple screening test to “save” the general public from their perceived incapacity for making a rational decision is neither rational nor beneficial.

References

1. AUA, “Prostate-Specific Antigen Best Practice Statement: 2009 Update,” www.auanet.org (2009).

2. AUA, “AUA responds to new recommendations on prostate cancer screening,” www.auanet.org (Oct. 7, 2011).

3. Simon N, “Should you have a PSA test for prostate cancer?” AARP Bulletin (Oct. 12, 2011).

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Dr. Bretan, a urologist in private practice in Novato, is president of MMS.

Email: bretan.surgery@usa.net