One man’s OpEd is not the only form of truth


Yesterday, Dr. Deepak Kapoor, a urologist and the Chairman of Health Policy for the Large Urology Group Practice Association (LUGPA), published his opinions about PSA testing and risk for prostate cancer based on such testing in an OpEd article in the New York Times.

Dr. Kapoor is, of course, fully entitled to express his opinions. And some — but perhaps not all — of the arguments that he put forward in his article are fully justifiable.

What is really interesting about this article, however, is the furore which it has led to in the hundreds of comments, which range from the sensible to the purely opinionated and to the downright rude and ridiculous.

The problem with PSA testing is that its value depends, to a very high extent, on how well it works to do exactly what in each individual patient who has such a test, and how the information provided influences the opinions of each patient, that patient’s physician advisors, and that patient’s other close friends and family members. In the vast majority of cases, PSA data don’t offer anyone any type of absolute truth. Men with PSA levels of < 1 ng/ml can get diagnosed with high-risk prostate cancer … and men with PSA levels of > 20 ng/ml may not have prostate cancer at all.

No one with half a brain would argue that the PSA test is a “bad” test. It isn’t. It is enormously valuable in monitoring men with prostate cancer post-treatment (assuming they actually needed that treatment). It also has great potential value in helping to identify men with prostate cancer and other prostate disorders who really do need to do something about their disorder. But that is not all it does. All too often it also scares many patients (with the tacit support of their doctors) into doing things that are not necessarily a good idea at all.

We have been making a little progress on how to use PSA testing well in the past few years. Here are some of the things that we now know:

  • It is probably a good idea for most men to get a baseline PSA test taken in their 40s to help them develop a plan for the future regarding their level of risk for clinically significant prostate cancer. But that baseline PSA level is still not an absolute truth. It needs to be considered in combination with a variety of other risk factors (race, family history, diet, etc.).
  • It is probably not a good idea for most men to just “react” to a single elevated PSA level if they have one between (say) 3.0 and 5.0 ng/ml by rushing off to get a biopsy (unless there are other potential indicators of risk as well). The wise patient and his doctor would do better to repeat such a PSA test after a month or so. It might have dropped back down again. PSA levels go up and down based on things as simple as the time of day in otherwise healthy men.
  • It is probably unnecessary for the vast majority of men to get repetitive, annual PSA tests done unless they are known to be at elevated risk for clinically significant prostate cancer for one or more reasons.

Furthermore:

  • We now have a whole range of additional tests that can be carried out to help a man know (a) whether he really does need a biopsy and/or (b) whether he really does have clinically significant prostate cancer that needs treatment (as opposed to indolent prostate cancer that can just be monitored) … so a PSA test is not, any longer, a test that should be sued on its own to determine whether a man either needs a biopsy or needs treatment if that biopsy happens to suggest the presence of low-risk (or even some intermediate-risk) prostate cancers.
  • We also know that a high percentage of men diagnosed with lesser-risk forms of prostate cancer don’t actually need treatment at all. They can simply be monitored over time … and may well find that they can live another 20+ years with a high quality of life and no risk for metastatic disease.

What we do not have, however, as yet, is any type of absolutely accurate method to determine with certainty who needs treatment for prostate cancer if they have an elevated PSA level. Biopsies can’t do that (even when they are MRI/TRUS fusion guided). Genomic testing of biopsy specimens can’t do that. Tests like the 4KScore and phi tests can’t do that. In the end, a patient and his doctor still have to make a judgment call. And all too many men still respond to the need for that judgment call with a strong dose of the fear associated with the use of the word “cancer”.

It would be lovely if someone could come up with a simple blood or urine test that could really tell us — with 95 percent accuracy (or something like it) — that a specific individual patient did or did not have prostate cancer that really needed to be treated within the next 3 to 6 months (as opposed to being monitored). But we don’t have such a test, and it is unrealistic of any sensible cancer advocate to think that we are going to be able to stop every case of metastatic prostate cancer through the use of PSA testing. Most men still don’t go and see a doctor at all if they can avoid it! That’s a cultural fact of life.

So long as we go on re-fighting the PSA screening wars, we are not going to make any significant progress toward a better way to assess risk for prostate cancer. The PSA test is what it is — an indicator of the potential for any one of several types of prostate/urinary tract problem. And that is all it is. Getting an annual PSA test — and especially getting an annual PSA test while simultaneously refusing to have a digital rectal examination — is not a way to manage risk for prostate cancer.  On the other hand, not getting a PSA test when you need one (for all sort of possible reasons) is about as smart as not getting a vaccination against measles or tetanus or a whole bunch of other deadly disorders. You may well not need that vaccination. And you may well find you did not need the PSA test (just as you may never need certain types of vaccination) … but under the right conditions, any of these actions might help to save your life.

If we could develop an actual vaccine that prevented all forms of low-risk prostate cancer, then we might be able to vastly reduce the number of men who are currently getting over-biopsied and over-treatment. Better still, if we could develop a vaccine that prevented the vast majority of prostate cancers, then we would be even better off!

4 Responses

  1. A lot of “ifs”. While I see holes in Kapoor’s article I do agree with him that with more conservative approaches in place and a less aggressive urological physician pool, it can be argued that the data used by the USPSTF to make the Grade D Recommendation is already outdated. That in fact that some level of reduction in the treatment morbidities may be suitable for the USPSTF to reconsider their recommendation. What the level needs to be is unclear.

  2. Well, Sitemaster, you provided sufficient explanation that I do not have to comment at all. Well done!

  3. Personally, I find little to disagree with in the Op-Ed … the PSA test is solely about information, not treatment. It is one of the simplest and best indicators that further tests may be indicated and should be pursued.

    If a reduction in testing does in fact lead to later stage diagnosis, it is inevitable with today’s treatments that in time we will see an increase in disease-specific mortality. For me and many others, that alone justifies a change in the USPTF recommendation.

    By the by, there is a groundswell of discontent, not to mention embarrassment, that when the prostate cancer grassroots community was recently requested to lobby our Congresspersons for continued CDC funding for prostate cancer, the prostate cancer organizations did not advise that the CDC endorses the USPTF line on PSA testing.

  4. Beware of the self-referring doctor.

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