Thursday, November 6, 2008
Prostate Cancer Screening - muddled and confusing
Prostate cancer is the most common nonskin cancer in men in the United States and 1 in 6 men will receive this diagnosis in their lifetime. The Prostate-specific antigen (PSA) test was approved by the FDA as a screening test for prostate cancer in 1986 and its use has increased since that time. Most male patients are aware of the test and ask for it at their annual exam.
What is little known by patients, is that the PSA test is not specific for prostate cancer. Men can have an elevated level for no disease reason, or it can be elevated for other common conditions like benign prostatic hypertrophy or prostatitis.
In 2002, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for prostate cancer. They found inconclusive evidence that screening and early detection improved health outcomes.
A new study was conducted by the same task force this year and published in the Annals of Internal Medicine. The researchers looked at the PSA test and asked three new key questions that were not asked in 2002:
1. Does screening for prostate cancer with PSA as a single test, or multiple tests over time decrease morbidity or mortality?
2. What are the harms associated with PSA?
3. What is the natural history of PSA-detected, non palpable, localized prostate cancer?
Their recommendations remain the same as 2002. They do not recommend routine PSA testing in men as a screen for prostate cancer. They state it is associated with psychological harm, possibility of erectile dysfunction, urinary incontinence, bowel dysfunction even death if treated. And its potential benefit remains uncertain. They recommend against testing any man over age 75 years.
So, there you have it. Evidence based medicine. The major medical associations like the American Academy of Family Physicians, the American College of Preventive Medicine, The AMA and The American College of Physicians recommend discussing the "risks and benefits" with patients and consider the patients' preference.
It is no surprise that the American Urological Association recommends offering PSA and digital rectal examination to men annually beginning at age 50. The urologists benefit from elevated PSA levels.
I would bet that there are very few physicians who will take the time to try and explain this study to their male patients. Every patient I have ever had believes if a test is available that "might" detect cancer...they want it.
With the escalating cost of health care, out out of control malpractice lawsuits and the bankrupt Medicare system , we are going to need to tackle these thorny issues of everything for everyone. There are so many unproven tests and treatments in Medicine and we have not had the will or the leadership to say "no" when there is no proven benefit.
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