Should Obama Get a PSA Test? On Prostate Cancer Screening and Comparative Effectiveness
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PSA screening
Finally, a column that makes sense. Thank you Dr. Healy, especially for pointing out that the screening techniques in the "new" studies are already obsolete so even once the results are complete in another 10 years, they will be of historical, not medical, value. Hopefully this round of controversies will result in more men knowing more about their prostates, and how to deal with prostate cancer. Or perhaps the anti screening forces would have us men believe that it's better to not even know about prostate cancer -- as we might be caused undue worrying.
Dr. Healy responds
A few comments to clarify some of the readers concerns:
First: Mortality rate was calculated by the number dying from prostate cancer as a percent of the total number of healthy men screened -- compared to the number dying of prostate cancer in the unscreened control group Five or ten year survival rates might look artificially better because of early detection, but not mortality. Also, in the US we have seen a fall off in the absolute number of men dying of prostate cancer, despite a larger and older population.
Second: Prostate cancer is generally slow growing and one would not expect to see much of a mortality difference until after ten years. These were interim reports. The studies are on going and trends in the European study suggest, at least, that mortality differences will widen -- with the screened group continuing to do better.
Third: Yes, the complications that can be associated with treatment of prostate cancer can be serious and affect quality of life. And every prostate cancer does not need aggressive treatment. For those that do need therapy, the side effects must be understood, but also put in context of the symptoms of advanced prostate cancer as it spreads locally, affecting bladder, bowel and sexual function, and spreads to bone and other parts of the body.
The decision to be screened or not is entirely up to the patient, as it should be. And therapy, if prostate cancer is present, should be as well. The information that will help doctors make recommendations and patients make choices is what these and other studies are about. They need to be looked at in detail and not be dismissed with headlines that can often be misleading, if not wrong.
I agree, Dr. Healy's conclusions and suggestions are suspect
The most sobering piece of information isn't simply that 48 men would need to be 'treated.' 48 teated men would risk side effects such as urine incontinence and impotence when treated with surgery, and with painful defecation and chronic diarrhea when treated with radiation. I'm shocked that Dr. Healy doesn't mention this at all in her article. That she does mention the 20% reduction in mortality, without mentioning what the mortality rate is, I also find shocking. The number was small - for every 10,000 men screened there were seven fewer deaths after nine years. None after ten years. Why do doctors pretend that their patient should make the decision, when they are clearly biased and don't give them all the information?
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Cancer orgs recommending screenings?
Dr. Healy states that "...In contrast, based on the same body of research, urologists and cancer groups recommend routine screening for men over age 50 and in the 40s for those at high risk, including African-Americans and those with a family history of prostate cancer."
Other than the American Urological Association and few other trades groups, I don't think any credible cancer groups have embraced routine PSA screenings for average risk men in the US. I think they emphasize shared decision-making and provide a very nuanced view-- both in terms of screening & treatment for localized prostate cancer.
Cancer orgs recommending screenings?
Dr. Healy states that "...In contrast, based on the same body of research, urologists and cancer groups recommend routine screening for men over age 50 and in the 40s for those at high risk, including African-Americans and those with a family history of prostate cancer."
Other than the American Urological Association and few other trades groups, I don't think any credible cancer groups have embraced routine PSA screenings for average risk men in the US. I think they emphasize shared decision-making and provide a very nuanced view-- both in terms of screening & treatment for localized prostate cancer.
Dr. Healy's conclusions and suggestions are suspect
Dr. Healy writes: "Prostate cancer mortality rates have plummeted in the United States over the past 20 years, coinciding with the widespread use of PSAs. (No such drop has occurred in Europe, where PSA screening, by policy, is uncommon.) This suggests—though it certainly doesn't prove—that PSA screening saves lives."
However, if more silent cancers that never would have killed American men are now being found because of more American PSA testing, then by default, the mortality rate would plummet. You're now calling more things "cancer" – many of which wouldn't have killed a man anyway. Dr. Barry Kramer of the National Institutes of Health calls it a pseudo-epidemic. So Dr. Healy’s example certainly DOESN'T prove that PSA screening saves lives.
The entire premise of the article about whether the President should get a PSA test - while provocative and probably meant to catch eyeballs - misses the conclusion most experts reached after the recent studies. When evidence raises so many questions about PSA screening, it becomes essential that a man discuss the potential benefits AND harms with his own caregiver. It's not an item up for debate by a magazine or by a urologist who won't even see the President.
Professor Gary Schwitzer
University of Minnesota School of Journalism & Mass Communication
Publisher, HealthNewsReview.org
