|Should I get the PSA test for prostate cancer?|
Dr. Robin Roberts
Published: Jun 12, 2012
Healthy men should no longer take the PSA (prostate specific antigen) blood test to detect prostate cancer as a routine or screening event. The test does more harm than good. So was the final conclusion and recommendation of the United States Preventive Services Task Force (USPSTF) on Monday, May 21, 2012.
The statement came as no surprise. Despite the protest and outrage from physician organizations including the prominent American Urological Association and several U.S.-based prostate cancer advocacy, education and support organizations, the task force refused to waver from their earlier draft statement issued in November 2011.
The task force’s recommendation was national and its impact, immediate. On the day of its announcement, the statement was the evening news on all the national and local television and radio stations. The following morning, it was headlines in the print media, too.
Having led the charge over the past 20 years for Bahamian males to get their routine PSA testing, I am obligated and mandated to outline and define the issues of this PSA testing controversy and state my opinion as well. My position is clear — the task force’s final recommendation is a backward step for us in The Bahamas.
It is a major threat to the advances in the healthy lifestyle behaviors that we in the Cancer Society of The Bahamas have tried to inculcate in our male population over the past 15 years.
Why should we be concerned about the task force’s recommendations on PSA testing in The Bahamas?
The task force’s interest had little focus on the African American population. Not surprisingly, men of African ancestry comprised only 15 percent of the American-based screening program and none in the European. While it is acknowledged that men of African ancestry are at higher risk for prostate cancer, the task force maintains that the available evidence does not allow us to know with any certainty whether the balance of benefits and harms is different for men at increased risk. Like all who oppose the task force’s conclusions, this is where I part ways with this particular issue too.
First and foremost, we must recognize that in men of African ancestry, (that is) men of Black heritage have different prostate cancer biology. When we present with prostate cancer for the first time, in unscreened populations, we present with prostate cancer that is much more progressive — at least twice as advanced, and we are up to four times more likely to die from it.
Research has also shown that prostate cancer in black men grows at a faster rate and is more likely to spread earlier compared to prostate cancer in the white male populations. When black men are diagnosed with cancer, at the same time of onset as their white counterparts and treated at the same time, our outcome with regard to living longer is the same, early or late. However, if we are diagnosed at a later stage or if we delay treatment, our results are worse. We die earlier and suffer more from the devastation of this cancer. These are the facts.
Why is this?
For black men, there is no doubt that the answer is somewhere in the genes. As a comparison, let’s look at the research on breast cancer in The Bahamas. The evidence suggests that the genetic factors are reasons why breast cancer is so deadly in our female population. There is a “bad gene” that can cause breast cancer and our Bahamian females inherit it.
Dr. Judith Hurley, a breast cancer specialist at the University of Miami School of Medicine and Dr. Theodore Turnquest of our Oncology Center at PMH (Princess Margaret Hospital) reveal that breast cancer develops at an earlier age in The Bahamas with the average age of diagnosis in Bahamian women at 42 years, compared to 62 in the United States. Moreover, 45 percent of Bahamian women diagnosed with breast cancer are in the late stages of cancer, compared to 12 percent of women diagnosed with breast cancer in the U.S. (United States).
Dr. John Lunn, medical director of the Bahamas Breast Cancer Initiative noted: “Bahamian women have the highest prevalence of this genetic [bad gene] mutation out of any population in the world, as 45 percent of women under 40 diagnosed with breast cancer have been found to have a BRCA1 [bad gene] mutation.”
A woman without a mutation has a 13 percent chance of developing breast cancer; with one or more mutations, the risk jumps to between 36 percent and 85 percent.
It is of great interest that research evidence indicates a high association of the BRCA1 gene with prostate cancer as well. (Are Bahamian men transmitting the breast cancer genes to their daughters? Food for thought!)
The Health Information and Research Unit database in our Ministry of Health cannot be ignored. In The Bahamas, 85 percent of the men are of African ancestry (probably higher with our interracial mix) and prostate cancer is the leading cause of death in men dying from cancer. More importantly, my research over the past 20 years indicate that approximately 80 percent of the men who present with prostate cancer for the first time have advanced prostate cancer and they fall in the high risk group with a 50 percent risk of disease recurrence within five years.
Prior to PSA testing, our prostate cancer outcomes mirrored those of all other countries; this was a global phenomenon. Since the introduction of PSA testing however, what has become obvious is that in those countries that have undertaken routine annual testing and screening, there has been a major shift in first time presentations of the cancer — a complete reversal. Now, in 80 percent of the men with cancers that are diagnosed early, the cancers are confined to the prostate and have the potential to be cured. The 40 percent decrease in death rates and 75 percent decrease in advanced disease presentations are evidence of the impact of PSA testing. In developing countries, where men have not undertaken these healthy choices, this early occurrence — the stage migration of prostate cancer, has not occurred. Clearly this indicates that too many Bahamian men are not
Unfortunately in The Bahamas, our Health Information and Research Unit of the Ministry of Health indicates also that the mortality rate for men dying from prostate cancer over the past 20 years has not decreased at all. Worst, the evidence indicates that our death rates have been increasing.
Currently, Bahamian men are not having regular PSA testing; the task force’s recommendations can only make it worse. It is the wrong message to send our Bahamian males.
In addition to my own views and research, many urologists, support groups and I, are critical of the task force’s statement and adamantly oppose their views, interpretations and conclusions. The responses discrediting the statements were immediate, furious, and distributed widely as well.
The American Urological Association (AUA) was outraged at the USPSTF's failure to amend its recommendations on prostate cancer testing to more adequately reflect the benefits of the prostate-specific antigen (PSA) test in the diagnosis of prostate cancer.
“It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African American men. Men who are in good health and have more than a 10 to 15 year life expectancy should have the choice to be tested and not discouraged from doing so.”
The AUA has a membership of over 18,000 urologists worldwide. At the panel discussion of the AUA annual conference in May 2012, the urologist opinions were vehement: Many older urologists remember a time when they regularly saw men with advanced prostate cancer at their first urology consult.
"It was as if people were drowning all around us," said Dr. Ian Thompson, director of the Cancer Therapy & Research Center at the University of Texas Health Science Center at San Antonio, and chair of the AUA prostate cancer guideline panel. When the PSA test came along in the 1980s, urologists saw it as a life preserver that could save patients’ lives by detecting prostate cancer at an earlier stage.” "Telling us to cease and desist from offering PSA tests is just callous," said Dr. William Catalona, professor of urology at the Feinberg School of Medicine, Northwestern University, in Chicago, Illinois.
So why has PSA testing become such a controversial issue?
The initial use of PSA was to determine the recurrence of prostate cancer after the cancer has been treated. This use of the PSA test remains without question. PSA is extremely accurate in detecting if and when the prostate cancer recurs.
PSA can detect the recurrence of the cancer in very small or microscopic amounts, months to years before the cancer reveals itself at detectable levels by x-rays or before the person experiences symptoms or signs of the cancer reappearance. When PSA was discovered initially, it was used purely for this purpose. The use of PSA for detecting the first presence of prostate cancer, (that is) in diagnosing it, is where and when the controversy began.
The logic for a wider use of PSA test was quite simple: PSA was great for detecting very small and early recurrences. Why not use it for diagnosing the cancer from the earliest onset? The cancer would be detected early before it spreads outside the prostate, destroyed completely and the patient would be cured. In this way, prostate cancer detection and treatment planning was identical to breast and cervical cancers in females. The PSA test being equivalent to the mammogram or the PAP test.
So why the PSA test controversy?
The spotlight is on screening: It is imperative to understand screening in the context of diagnosing a cancer. A screening program is introduced to detect a disease that is very common, producing significant suffering (or morbidity) and is a major cause of death (or mortality) in a community. The assumption is that if the condition is detected early, it can be treated effectively to reduce suffering and its cancer-related deaths. Screening is the process whereby the healthcare providers reach out into the community, summon and test the healthy residents (that is, without symptoms), with the intent to detect the early occurrence of the cancer and thus treat and eradicate the cancer in this early stage. In a successful screening program, less people will die because the cancer is detected early and treated effectively. (Despite the same outcome, technically screening is quite different from the individual who seeks to have his prostate test during his annual physical examination. One presumes that the individual is healthy at this office visit for the annual routine physical examination. PSA testing on this occasion would be termed an early detection test; the term screening should be reserved for testing a population of people at one time.)
The task force based its recommendations on the results of two large clinical research studies reported in 2009. The United States PLCO (Prostate, Lung, Colon and Ovarian) Cancer Screening Trial which assigned randomly 76,685 men ages 55 to 74 years into two groups, one to receive annual screening for six years and the other the “usual care,” (that is) no routine PSA testing.
The ERSPC (European Randomized Study of Screening for Prostate Cancer) similarly assigned randomly 162,243 men aged 55 to 69 years into two groups, one to receive PSA screening once every four years and the other to an unscreened control group. The task force reviewed the results of these two major screening programs on the healthy males and made their conclusions. The American study showed that the group that was screened and tested regularly, showed no decrease in the death rates when compared to the “usual care” group that had no regular screening or PSA testing. In the European screening program there was evidence confirming a reduction in death rates of the group that had regular PSA testing, but the task force was not satisfied that the difference was large enough.
All eyes were on these two studies
What made these two studies so outstanding? Unlike any of the studies before in the merits of PSA testing for early detection, they undertook to measure that any differences that occurred between the two groups would be due solely to having the PSA screening. These were true experiments. In prior research studies, while the research determined that the PSA was beneficial, other factors could have been making for better survival, such as better surgical techniques or hospital care, not just the PSA testing.
The task force had great concerns on several other issues emanating from PSA testing:
Treatment complications: Those who were proven to have prostate cancer and were treated, incurred complications that impacted significantly and adversely on the man’s quality of life. If they had surgery to treat the cancer, 29 out every 1,000 were sexually impotent afterwards, 18 of every 1,000 were incontinent of urine and one of 3,000 died. Those who had the alternative treatment – that is, radiation – had complications noted as well.
Undue psychological stress: An elevated PSA is not conclusive for prostate cancer. Any prostate disease or disorder can cause an elevated PSA. If the PSA test is elevated, the man must have a prostate biopsy to determine if it is due to prostate cancer or to some other non-cancerous prostate condition. This requires taking direct tissue samples via needle stabs into the prostate called a biopsy procedure. The samples are forwarded to the pathologist to view under the microscope for the presence of prostate cancer. About 10 percent of men screened will have an elevated PSA and overall about two percent of them will be proven positive for the cancer. Those men with elevated PSA but not due to prostate cancer are said to have falsely elevated PSA test results. The task force determined that the men with a negative biopsy, thus false positive for prostate cancer, suffer significant psychological trauma awaiting the result of the biopsy.
Biopsy complications: Men are also at risk for complications of the biopsy such as discomfort, infections and bleeding.
Unnecessary treatment: The biology of prostate cancer growth still eludes physicians and researchers. While some prostate cancers result in death due to their rapid uncontrolled growth, many cancers are very slow growing, and in fact, never progress at all. Most men die with prostate cancer rather than because of it. Those against PSA testing suggest that the cancer is detected too early, and would have never grown to cause any cancer problems or death. If left alone, these men would never have succumbed to the complications of a biopsy, or worst still, the treatment.
The task force, after having deliberated over PSA testing for the diagnosis of prostate cancer for over 10 years, gave PSA testing for the screening of prostate cancer a “D” rating for men of any age. In this regard the task force concluded that PSA testing does not reduce the death rates of men dying from prostate cancer, and may cause more harm than benefit and moreover, probably in men who should not have been treated in the first place. This dictate forbids physicians from mentioning, introducing or suggesting to patients to have a PSA test routinely unless the patient specifically makes that request. And in the event the patient does, the physician must inform him fully of the risk, outcomes and complication of the test, biopsy, and the implications for treatment.
While this article focused heavily on men of African origin, no Bahamian male — Black or White should delude himself that prostate cancer does not effect all groups. This cancer remains the leading cause of death for both black and white men alike, including Bahamians.
On behalf of the Cancer Society of the Bahamas, I continue to recommend and urge all Bahamian men between the ages of 40 to 70 years, to have their annual rectal digital examination and PSA blood test for the early detection of prostate cancer. The life you save from this cancer’s painful illness and death, may be your own.