“It's all we have” versus “More trouble than it's worth.”
Weighing the pros and cons of the PSA blood test for prostate cancer was not merely an academic exercise for Omahan Ron Hager.
The prostate is a gland found only in men. It is just below the bladder and in front of the rectum. The size of the prostate varies with age. In younger men it is the size of a walnut, but it can be much larger in older men.
A discussion about prostate cancer screening should take place at age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
Officials estimate that in 2011 there will be about 241,000 new cases of prostate cancer in the United States and about 33,700 deaths from the disease.
Early prostate cancer often causes no symptoms. It may be found by a PSA test or a digital rectal exam. Problems with urinating could be a sign of advanced prostate cancer, but more often this problem is caused by a less serious disease known as BPH, or benign prostatic hyperplasia.
Symptoms of advanced prostate cancer are:
>> Trouble having or keeping an erection (impotence)
>> Blood in the urine
>> Pain in the spine, hips, ribs or other bones
>> Weakness or numbness in the legs or feet
>> Loss of bladder or bowel control
Other diseases can cause those symptoms as well.
If certain symptoms or the results of early tests suggest that a man might have prostate cancer, his doctor will do a prostate biopsy to find out whether the disease is present.
Source: American Cancer Society
Two years ago, when he was 50, Hager had a PSA test because of a medical insurance upgrade. His reading was 55 nanograms of prostate-specific antigen per milliliter of blood, which is considered a highly elevated level.
The high score led doctors to recommend that Hager's prostate be biopsied — a review of which, he said, revealed an aggressive form of prostate cancer. After weighing his treatment options, Hager chose to have his prostate removed.
Had he not had the PSA test, Hager said, “I'd probably be dead by now.”
The use of the PSA test to screen for prostate cancer is under fire in a draft recommendation, by the U.S. Preventive Services Task Force, set to be released on Tuesday.
The task force draft says healthy men no longer should get a PSA test because, overall, it doesn't save lives and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many men. It also says there is no evidence a digital rectal exam or ultrasound is effective, either.
The task force's draft recommendation is “possibly premature and dangerous,” said Dr. Chad LaGrange, a urologist at the University of Nebraska Medical Center. “The only way to diagnose prostate cancer is if you screen ... The next question is whether to treat.”
He agrees that not every man over a certain age needs to undergo PSA screening. “The decision to screen,” he said, “should be based on overall health, life expectancy, family history and symptoms.”
Dr. Shailendra Saxena, an Omaha family practice physician, also disagrees with the task force. Saxena, who also is an associate professor of family medicine at the Creighton University School of Medicine, looks at several PSA-related factors in addition to conducting a digital rectal exam when trying to determine if a patient may have prostate cancer.
He agrees that diagnosing prostate cancer in a 70-year-old doesn't help him much, because the man's life expectancy is not going to change a great deal with or without a diagnosis. But telling a patient of 50 “not to get a PSA — that is upsetting to me.”
Dr. William Hay, also an Omaha family physician, questions the PSA test's value. “It has a very high false-positive rate,” he said. “Just an enlarged prostate can cause a high PSA level.”
Even if cancer is detected, Hay said, “a lot of prostate cancers are reasonably benign. They won't spread. They won't kill you. If you live long enough you will almost certainly get prostate cancer.”
But testing, he said, can lead to “a lot of problems; you can cause a lot of worry.” Treatment of the cancer, he said, causes erectile dysfunction in about 30 percent of patients and incontinence in about the same percentage.
“How much money are we going to spend and how much incidental injury are we going to cause without knowing that we're doing any good?” Hay said.
LaGrange noted that since PSA screening became widespread in the 1990s, prostate cancer death rates have dropped almost 50 percent, and the absolute number of men dying from prostate cancer is dropping.
He said that if a man's prostate cancer is very unlikely to spread or cause death, he counsels them that it be monitored, not necessarily treated. This often is called “watchful waiting.”
Dr. Luke Nordquist, an Omaha oncologist who is treating Hager, said: “As a society and as doctors and experts and scientists, we have to do better determining who needs screening and who doesn't.”
Instead of abandoning the PSA test, he said, maybe men should be tested earlier, in their 30s, to avoid false positives from enlarged prostates that older men experience.
Nordquist cited a study published this year of more than 21,000 men. It found that men who had low scores on three PSA tests between the ages of 40 and 60 had a very low risk of developing metastatic prostate cancer and therefore could avoid future or more intensive screening.
“Any time we can determine who is at higher risk of developing life-threatening cancer and detect it earlier while ... (avoiding) testing the whole population who won't benefit,” he said, “is a good thing and more cost-effective for society.”
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A previous version incorrectly identified Oncologist Luke Nordquist's area of medical specialty.