Albin, Richard J. "The Great Prostate Mistake," New York Times, 10 March

 

Albin, Richard J. "The Great Prostate Mistake," New York Times, 10 March
2010, p...

Tucson

EACH year some 30 million American men undergo testing for prostate-specific
antigen, an enzyme made by the prostate. Approved by the Food and Drug
Administration in 1994, the P.S.A. test is the most commonly used tool for
detecting prostate cancer.

The test's popularity has led to a hugely expensive public health disaster. It's an
issue I am painfully familiar with I discovered P.S.A. in 1970. As Congress
searches for ways to cut costs in our health care system, a significant savings
could come from changing the way the antigen is used to screen for prostate
cancer.

Americans spend an enormous amount testing for prostate cancer. The annual bill
for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and
the Veterans Administration.

Prostate cancer may get a lot of press, but consider the numbers: American men
have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but
only a 3 percent chance of dying from it. That's because the majority of prostate
cancers grow slowly. In other words, men lucky enough to reach old age are much
more likely to die with prostate cancer than to die of it.

Even then, the test is hardly more effective than a coin toss. As I've been trying to
make clear for many years now, P.S.A. testing can't detect prostate cancer and,
more important, it can't distinguish between the two types of prostate cancer
the one that will kill you and the one that won't.

Instead, the test simply reveals how much of the prostate antigen a man has in his
blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of
the prostate can all elevate a man's P.S.A. levels, but none of these factors signals
cancer. Men with low readings might still harbor dangerous cancers, while those
with high readings might be completely healthy.

In approving the procedure, the Food and Drug Administration relied heavily on a
study that showed testing could detect 3.8 percent of prostate cancers, which was a
better rate than the standard method, a digital rectal exam.

Still, 3.8 percent is a small number. Nevertheless, especially in the early days of
screening, men with a reading over four nanograms per milliliter were sent for
painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was
almost always pushed into surgery, intensive radiation or other damaging
treatments.

The medical community is slowly turning against P.S.A. screening. Last year, The
New England Journal of Medicine published results from the two largest studies
of the screening procedure, one in Europe and one in the United States. The results
from the American study show that over a period of 7 to 10 years, screening did
not reduce the death rate in men 55 and over.

The European study showed a small decline in death rates, but also found that 48
men would need to be treated to save one life. That's 47 men who, in all
likelihood, can no longer function sexually or stay out of the bathroom for long.

Numerous early screening proponents, including Thomas Stamey, a well-known
Stanford University urologist, have come out against routine testing; last month,
the American Cancer Society urged more caution in using the test. The American
College of Preventive Medicine also concluded that there was insufficient
evidence to recommend routine screening.

So why is it still used? Because drug companies continue peddling the tests and
advocacy groups push "prostate cancer awareness" by encouraging men to get
screened. Shamefully, the American Urological Association still recommends
screening, while the National Cancer Institute is vague on the issue, stating that
the evidence is unclear.

The federal panel empowered to evaluate cancer screening tests, the Preventive
Services Task Force, recently recommended against P.S.A. screening for men aged
75 or older. But the group has still not made a recommendation either way for
younger men.

Prostate-specific antigen testing does have a place. After treatment for prostate
cancer, for instance, a rapidly rising score indicates a return of the disease. And
men with a family history of prostate cancer should probably get tested regularly.
If their score starts skyrocketing, it could mean cancer.

But these uses are limited. Testing should absolutely not be deployed to screen the
entire population of men over the age of 50, the outcome pushed by those who
stand to profit.

I never dreamed that my discovery four decades ago would lead to such a
profit-driven public health disaster. The medical community must confront reality
and stop the inappropriate use of P.S.A. screening. Doing so would save billions
of dollars and rescue millions of men from unnecessary, debilitating treatments.