Well an OpEd in the New York Times today is going to upset a lot of men (and maybe a lot of women too) … but then as the man who initially identified prostate specific antigen, Dr. Ablin is certainly entitled to express his opinion.
To read his OpEd, you should just click here. And yes, we also have an opinion about this.
The problem with the use of the PSA test (in our opinion) is not its use. … It is its mindless use. The PSA test doesn’t give a black and white answer to anything in an undiagnosed patient, and it shouldn’t be used as if it did.
In our view most men do not need PSA tests on an annual basis to “screen” the entire population for prostate cancer. And probably tens of thousands of men who go on to get a positive biopsy test after an initial PSA test, and then go on to get treated because there are identifable cancer cells in their prostates, did not need to be treated at all. They should simply have been monitored in some way, because they very probably had clinically insignificant prostate cancer.
But the genie is out of the bottle, and we aren’t going to be able to cram it back in. We will no more be able to stop the use of the PSA test to identify men at risk for prostate cancer (even if we wanted to) than we would be able to keep bad drivers off the roads.
The two questions that we are all facing at this time are:
- How do we use the PSA test to assess prostate cancer risk much better than we do now?
- How fast can we find and develop a test (or a group of tests) that can actually distinguish with a high degree of accuracy between men who are at risk for clinically significant prostate cancer (and therefore might either progress to have metastatic disease or actually die of prostate cancer) and those with some cancer cells in their prostate but who have minimal risk of clinically significant disease?
The media, of course, will continue to paint all this as a “controversy,” and some people will insist on looking at this as a “black or white” issue, and will therefore forment this controversy. Those of us who tend to think with our brains as well as our emotions wish to seek a middle ground that is actually intended to ensure that we can:
- Optimize the probability of identifying men at risk for clinically significant (potentially lethal) prostate cancer as early as possible, so that they can be treated with curative intent
- Minimize the probability that men who really don’t need invasive treatment at all don’t suffer the harms of treatment.
This is not abortion folks! We should be able to work towards some common ground without all of the posturing and hysteria!
Search for new and
ongoing trials on the
CTAG PCa web site
What especially gets me PO’d is the recommendation against testing men 75 years old or more. I was diagnosed with Gleason 9 prostate cancer just a few months before my 75th birthday in 2004. If I hadn’t been treated then, I would be dead by now. But I am in good health and expecting at least another 10 years.
A simple calculation from published data will yield the result that there will be about 7,700 cases of aggressive prostate cancer annually among men 75+ years old. Apparently they are considered expendable.
I’m quoting the article here:
“Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer.”
Well I guess I am wasting my time trying to be a surviving prostate cancer advocate. So I’m stepping back to being a patient. It seems just reading those sentences lowers my quality of life. I still have my opinion, but it isn’t worth anything against such comments. After all, nobody in the medical community respects what I know about how my PSA screening was a good thing for me.
My moron opinion tells me the above sentences indicate (1) that nobody who does not have family history will benefit from testing (of course my father tested positive after I did) and (2) that PSA usefulness is best after treating an undetected disease. It seems to me the indication is that the only time to use PSA testing is after a positive biopsy post-DRE indicated a need for treatment, or after the disease had spread to the point of detection through symptoms indicating a need for treatment.
I am really tired of being aggravated by the medical and other prostate cancer community opinions. I guess I just have to live with the fact that at age 44, my advanced prostate cancer was overdiagnosed. …
“We should be able to work towards some common ground without all of the posturing and hysteria!”
If only … the voice of reason is drowned by the shrill cries of those who will not listen, will not see — maybe cannot think.
Just look at the responses to your post advertising this item on the PPML list. Any reference to your reasoned argument — NO. Any mention of the fact that Ablin discovered PSA and is therefore entitled to express and opinion — NO. Any reference to the fact that Albin acknowledges that there is a place for PSA testing — NO.
Bah!
But Terry, why blame the test and not the decision process that follows? Dr. Ablin doesn’t recognize the value of the test in early detection at the time that there is nothing better to alert men that something is wrong in prostateland. That is why some of us surviving prostate cancer because of the PSA test will never deny its value …
Ralph,
What I cannot understand amongst all the knee-jerk condemnations and claims to have been “saved” by a PSA test — often from men who needed no “saving” — is what precisely the objection is to the concept of “informed consent” for PSA testing.
The very people who would complain loudest about people being recruited for trials without informed consent seem to be the same ones who say, “Don’t tell a man anything about the PSA test and likely consequences, just give it to him, we know what’s best.”
Why not explain the vagaries of the PSA test, why not emhasize that the PSA test is not, Is Not, IS NOT PCa-specific, as you famously put it in a post many years ago?
As my new slogan has it:
“Prostate men need enlightening, not frightening.”
And until the numerous activists start concentrating on this rather than arguing about how many angels dance on the heads of a pin, I’ll keep bugging people to start working towards some common ground, without all of the posturing and hysteria!
Gentlemen:
You missed the point entirely. This is not about people. It is about money, politics, and the lean towards socialized medicine in the USA. For Christ’s sake, it is The New York Times!!!
Think about recent releases, less breast cancer screening, then less heart tests, and now less prostate. When you try to cover more people for basic care and spend less (?) money, you need to cut somewhere. Sure guys like me will die but more people will have coverage for the ‘flu. Just think about the guys from Canada and the UK who post here about not being able to get certain treatments.
“Who is expendable?” The cry went from women after the breast cancer announcement, and they backed off, but for men … most don’t want to be tested anyway.
It is money and politics as usual and there will always be some collateral damage.
Just my opinion.
And again the hysteria about socialised medicine.
I live in a country with socialised medicine. So far, I am greatly in favour of socialised medicine — at least the way it is practised here in Australia, where you can buy insurance as well as use the public facilities. We only buy hospital cover in case of emergency.
In the last 10 days I have had had appointments with doctor, dentist, cardiologist, jaw x-ray, PSA and other blood tests, picked up a month’s supply of the medications my wife and I are on — next week I have to see a specialist oral and maxillofacial surgeon to deal with my tooth problem.
The cost to me? $30 for the medication. The delays — none. I went from the dentist to the x-ray clinic, took the x-ray back to the dentist, and she made an appointment for me with the specialist.
I know it is not always so smooth, but can say that since we got back to Australia and started using the system in a BIG way, only once have I had to wait an annoyingly long time and that was at the oncologist where he was dealing with some very bad cases — he apologised and was prepared to spend as long as I wanted in discussing my problems. That was not my experience in the US, I have to say.
Terry,
Whoops you missed the point (again). It must be my fault.
No hysterics and I do not care to debate the merits of socialized medicine in Australia, although I am happy to hear it works so well for you.
My point is the article is politically motivated. You can disagree, but the timing of the article and the venue (the New York Times) cause me to discount it as just more political rhetoric.
Those interested in reading the Letters to the Editor of the New York Times in response to Dr. Ablin’s OpEd should please click here.
I must admit that I hadn’t checked on the AUA position lately, so this snippet was of great interest given the attacks on the ACS for saying the same thing:
“Regarding prostate cancer detection and diagnosis, the American Urological Association does not advocate universal yearly P.S.A. testing, nor does it support routine biopsy.”
And as a typical example of the kind of illogical reaction to Ablin’s comments there is this wonderful bit:
“In doing so, authorities like Dr. Ablin condemn tens of thousands of men to early, painful deaths each year.”
One of the things (among others) that bothers me about Dr. Ablin’s piece is his use of what I would call “semantic tricks.”
Firstly, the item is packed with emotionally charged scare words: mistake, hugely expensive, disaster, enormous, painful, damaging treatments, shamefully, skyrocketing, public health disaster, debilitating, etc. These are words that have no place in a rational discussion.
Another: he sets up a straw man and very bravely knocks him down. He writes “P.S.A. testing … can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.” In all the years I have been in the prostate cancer business, I have never once heard any medical professional claim that it could do that. He is accusing the test of a crime it never even thought about committing.
Another: He writes “American men have … “only” (my emphasis) a 3 percent chance of dying from it.” According to the 2000 Census data, there were over 50 million men in the U.S. age 40 and up. Three percent of that equals 1.5 million potential deaths from prostate cancer. I would not consider that a trivial consequence.
I could go on for many more paragraphs taking his piece apart. Others more expert than I have criticized this whole approach. I will end by violating my one of my own principles and call this a diatribe, in every negative sense of the word.
Just so that we are clear about the supposed 3% mortality rate … this is a factual inaccuracy in the Albin piece. The accurate statement would have been that, “Between 2% and 3% of all the men who are actually diagnosed with prostate cancer today will go on to die of it.” (That’s a very different number!)
… or, to put it another way, between 98% and 97% of these men will die of something else.
Identifying and treating prostate cancer does not make any man immortal (unfortunately).
Thank you, Sitemaster. I did not pick up on the inaccuracy involving the 3 percent figure.
Re-doing the math, we start with the roughly 200,000 new cases of PCa annually and take 2 to 3 percent of that and get 4,000 to 6,000 men dying. Yet the official projection for this year is 28,000 deaths from prostate cancer. This does not make sense. If prostate cancer is not a serious problem, why are so many men still dying of it? To me this is all further evidence of the lack of critical thinking in Dr. Ablin’s piece.
Dear Manny:
The statistics of prostate cancer incidence, prevalence and mortality are somewhat more complicated than a percentage of the number diagnosed in each specific year.
Please remember than most of the men dying of prostate cancer in 2010 were being diagnosed as long ago as 1990 (i.e., 10 to 20 years ago). So the question you need to address today is, how many men will be dying of prostate cancer in (say) 2030 compared to the new diagnoses today.
It is currently estimated that the vast majority of men with prostate cancer in the US today are diagnosed with localized, and therefore theoretically curable disease, and most patients so diagnosed are known to have a 10- to 20-year prostate cancer-specific survival. These men do not have the same disease risk profiles as the men being diagnosed in 1990 or even in 2000.
Mike