“What would YOU do doctor?” A urologist’s take on the PSA controversy

If you want to read a flawless analysis of the problem every patient faces when the topic of prostate cancer screening comes up, beg, borrow, or steal a copy of an editorial in the August issue of the Journal of Urology, entitled “What Would You Do Doctor?” by Joseph Smith, MD. Sadly this editorial is not freely available on line. It should be!

Dr. Smith carefully walks his readers through the conflicting issues that affect the value of screening, starting out, brilliantly, with a question: “What is a patient supposed to think when one learned body recommends that a PSA be obtained in all men at age 40 years and another strongly opposes PSA screening in anyone?”

He goes on to address the issue that many patients almost certainly place into their doctors’ laps: “What would you do if you were in my shoes doc?”

But Dr. Smith reminds us, along the way, of a number of facts that every urologist knows and that many men at risk are not considering with any degree of care:

  • Only a small proportion of men actually die of prostate cancer after up to 10 years of observation (which Smith carefully notes was confirmed by the PLCO and ERSPC studies earlier this year).
  • The idea that prostate cancer is “over-diagnosed” and “over-treated” is not new at all. (Says Smith: “Reports in the lay press create the impression that doctors are learning for the first time that prostate cancer is over diagnosed and over treated but that knowledge preceded the advent of PSA testing. Multiple publications in The Journal of Urology and elsewhere have addressed directly this very subject for decades, and have repeatedly urged the discovery of better prognostic parameters.”)
  • Seeking to diagnose prostate cancer is inevitably a “contextual” event. As Smith states, “For almost a quarter of the United States population the reward (or need) of smoking seems to outweigh the profound and proven health risks. The mental compartmentalization required for a man who presents for routine PSA screening with a pack of cigarettes in his shirt pocket is sometimes difficult to comprehend.”
  • “Even among urologists, a surprising number do not undergo routine PSA testing. However, most remember the patients they have seen who had a scary appearing cancer cured because of screening as well as the ones who suffer and die from prostate cancer.”

However, Smith also points out, equally carefully, that:

  • ‘[S]omeone is dying of prostate cancer. (Smith says in will be 35,000 men in 2009; the American Cancer Society estimates 27,500. Either way it’s too many.)
  • “[V]irtually every urological surgeon can identify patients in his or her practice who clearly seem to be beneficiaries of screening.” (Smith gives the example of “a 53-year-old man with a Gleason 8 cancer detected because of an increased PSA but whose postoperative PSA has remained undetectable for many years. Surely this man is cured of a cancer which otherwise would likely have been fatal.”)

Last but not least, he offers some advice to his colleagues that is good advice for patients too:

  • “The real governor of screening and treatment may best be applied once a diagnosis is made.”
  • “A clear benefit of some of the recent attention to this subject is that more patients are willing to accept a strategy of active surveillance when appropriate. “
  • “Undoubtedly, … a diagnosis of prostate cancer can initiate a cascade of events, a so-called slippery slope, wherein treatment is performed ‘just to be sure.’ “
  • “Maybe even more important for urological surgeons than making wise recommendations about PSA screening is to help patients put a diagnosis of prostate cancer in proper perspective and not let an overdone concern about cancer lead to unnecessary treatment.”
  • “With appropriate counseling and recommendation, the slope does not have to be so slippery.”

I have quoted mercilessly from Smith’s editorial because I believe the points he makes are of enormous importance to the prostate cancer community as a whole. I have been unable to contact anyone at the American Urological Association or at their publisher this evening to be able to obtain permission to use such extensive quotation without pre-approval, and I apologize for using them without due permission. Hopefully I will be forgiven. (I promise I’m not making any money by doing so!)

There is just one place that I disagree with Smith in this entire article. He criticizes the proposed idea that, “the doctor discuss the pros and cons of prostate cancer screening with patients, ” continuing by stating that “The naivete and impracticality of this approach are that it would require virtually an entire weekend seminar for a man to be properly informed.”

The “New” Prostate Cancer InfoLink would point out that only a tiny minority of men are actually diagnosed with prostate cancer prior to the age of 40. This means that the average male who is 16 years of age today has about 24 years to get relevant and approriate information about his risk for prostate cancer and decide how to act appropriately when necessary. We should start running those weekend seminars! Men are appallingly underinformed about their health — and we have only ourselves to blame for that!

9 Responses

  1. Perhaps the best article that you have published here to date!

  2. I suspect that the revulsion that arises from a cancer diagnosis (“I’ve got WHAT growing in me? Get it out! Get it OUT!) is rooted somewhere in the brain stem (think small rodents, snakes, and large insects), and that it would take more than a hundred years of weekend seminars to reach the ability for a rational trade-off between probabilities of progression and side effects/costs of treatment. (See The Science of Fear by Gardner)

    I would like to be wrong.

    If I’m not wrong, then either we continue as we have been, or someone’s going to say “no.” If the patient is willing to pay for the treatment out of pocket, this is probably a non-issue. But with insurance? Based on history (doctors prescribing antibiotics for colds, on demand) I expect that the decision to say “no” won’t be left to the physician.

    I would like to be wrong.

  3. I took special note of Dr. Smith’s remark, “Maybe even more important for urological surgeons than making wise recommendations about PSA screening is to help patients put a diagnosis of prostate cancer in proper perspective and not let an overdone concern about cancer lead to unnecessary treatment.” This has been my point from the get-go of the complaint that patients are being over-treated and using that as an excuse to claim that PSA testing is the cause. The only over-treatment occurs when the urologist or radiation oncologist pushes the patient to treatment despite a Gleason score 6 of with only one or two biopsy tissue samples evidencing less than 15% cancer presence. It is rare, even with this recent recognition of over-treatment, that physicians are explaining active surveilance as a reasonable option that, with continued monitoring, could provide many years needing no treatment — for some.

  4. Wow … Powerful stuff.

    A year and a half ago, following several “routine” PSA tests, my numbers started climbing. Several PSA tests and a biopsy later, I was diagnosed with Gleason 6 cancer. I was 53 when the PSA count started climbing. Well, after RALP (negative everything outside of the prostate) last October, everything is great.

    I hope I am cured, the odds are that I am. I pause frequently to think to myself … “What if I had never started getting the PSA test done at age 50?”

    I am terrified to think of that possibility. With 20-30 years of life expectancy, I would most certainly have faced a suffering death from that malignancy, had it not been discovered during a “routine” screening that some are saying was unnecessary!

  5. Great article (yet another hidden from most by the copyright curtain) and the comments are dead on.

    I’d offer that doctors have to be part of a systematic approach to educating men about prostate cancer screening and treatment before starting PSA screening — even if only to hand the patient a pamphlet and say, “Read this and call me back if you want me to send this vial of blood in for PSA testing. I (or some non-MD specialist) will be happy to answer any questions that you have about what it says.”

  6. I appear to be experiencing recurrent prostate cancer, with a slowly increasing PSA of 7.5, nearly 16 years after first diagnosis.

    At age 78, in otherwise excellent health, I’m not inclined to do nothing.

    The question is what to do.

  7. Phil: I have commented on your remarks on your page on the social networking site (a more appropriate venue for that sort of personal issue, I suggest).

  8. To do nothing is not an option.

    Of course I have a need and a right to know if I have cancer. And, if it is a significant cancer, I have a right to attempt to cure it, which only is possible if it is discovered and treated early.

    The U.S. Preventive Services Task Force has no right to say I cannot do what I must to survive.

  9. Phil: To be entirely fair to the USPSTF, they have never suggested that people should be denied the right to know if they have a risk for clinically significant prostate cancer.

    Their positions are: (a) That there is no category 1 evidence that mass, population-based screening for prostate cancer with tests currently available has a demonstrable impact on either survival or even risk for metastatic prostate cancer. This is true. (b) That the use of tests currently available to find prostate cancer in males of 75+ years of age is not recommended because the chances of harm resulting outweigh the chances of the good that may be accomplished. This may well also be true, but only in general and not in particular cases.

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