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Prostate Cancer Screening's Toll

One of the most controversial issues in men's health is whether a blood test commonly used to screen for prostate cancer is being overused.

Well, there's new evidence out this week that the test has led to a lot of men getting unnecessary treatment.

The test, known as the prostate-specific antigen (PSA) test, measures a protein in the blood produced by the prostate gland. Doctors started using it routinely around 1987 to spot men with prostate cancer early. Prostate cancer is diagnosed in more than 218,000 men in the United States each year. and kills about 28,000, making it the second leading cancer killer in men after lung cancer.

But because prostate cancer grows so slowly, it never causes problems for a lot of men who have it. Many end up dying of something else without ever knowing that they had it. Because of that, there's been an intense debate over whether routine PSA testing is excessive.

In the new study, H. Gilbert Welch of the VA Outcomes Group in White River Junction, Vt., analyzed federal cancer statistics between 1986 and 2005 and calculated that 1.3 million men had been diagnosed with prostate cancer since PSA testing began.
Of those, more than 1 million underwent treatment, most of whom probably did not need any treatment, according to a report in the Journal of the National Cancer Institute.

For every one man whose life was saved by PSA testing, at least 20 underwent unnecessary treatment that may have left them incontinent, impotent and suffering from other side effects, the researchers calculated.

"It's really important that men come into these screening decisions with full knowledge of the benefits and harms," Welch said during a telephone interview.

Welch also noted that PSA testing has meant that men tend to get diagnosed much younger than they used to. Diagnosis more than tripled since 1986 among men ages 50 to 59 and increased more than sevenfold among men under age 50.

In an editorial accompanying the study, Otis Brawley, the American Cancer Society's chief medical officer, said the findings underscore the need to find ways to identify the men with prostate cancer who really need treatment.

Brawley noted that the study comes at a time when the health care reform debate has focused attention on health care costs. One way to control spending, Brawley noted, is to reduce unnecessary treatment.

By Rob Stein  |  September 3, 2009; 8:00 AM ET
Categories:  Cancer , Medical Technology  
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Comments

This article makes me very cross,this test saves lives.if you catch prostate cancer earley you can live for many years.Once it has spread outside the prostate and this happens silentley with very few symtoms,it spreads to the bones and then you will die.It is very hard to get men to discuss health issues and to be proactive.My partener is only 67 and the cancer has spread to the bones so I know all about the anquish of this diseaes.I would do anything to encourage all men to have a PSA test every year

Posted by: ewellman | September 3, 2009 10:32 AM | Report abuse

Prostate surgery is not done solely on the basis of a PSA test. The test is an indicator that there may be cancer in the prostate. A biopsy is performed and if it is found to be positive the patient decides what treatment he wants. I am 60, had prostate cancer at 42, and would have been dead nearly 10 years ago if I had not had the surgery. I have none of the problems listed in the post. I urge all men over 40 to have the PSA test done. It saved my life.

Posted by: Directmale | September 3, 2009 11:07 AM | Report abuse

Sounds like the PSA test is kind of like those "whole body scans" that they advertise on the radio: sounds like a good idea, and some people swear that they "saved their life", but once you look at them scientifically, it turns out they cause a HUGE amount of painful, destructive overtreatment.

Those who would disregard this scientific study on the weight of a single anecdote, or based on a "gut feel", do so at their own risk.

Posted by: DupontJay | September 3, 2009 11:31 AM | Report abuse

There is nothing wrong with the PSA test which is just a blood test. It provides a hint that cancer may be there.
The problem starts whether a biopsy is necessary and depending on the biopsy results if treatment is necessary.
The urologist should guide patients what to do. From my own experience I get the impression that some HMO's are commercial enterprises where revenue counts.
The pressure to produce revenue has no place in healthcare. That is why we need reform. I do not understand politicians who listen at townhalls to ignorants as an excuse to boycott the President's initiative. They should be expelled from Congress.

Posted by: wremy | September 3, 2009 2:32 PM | Report abuse

I bought a book written by Dr. Patrick Walsh of Johns Hopkins (GUIDE TO SURVIVING PROSTATE CANCER) concerning prostate disorders, PSA testing, cancer etc, when I was fretting over abnormal PSA test results this year. This book is worth the $17 dollars many times over. I would suggest men or wives to buy this book when trying to make decisions about issues dealing with the prostate.

Posted by: 12oreo | September 3, 2009 3:17 PM | Report abuse

You are really doing men (and their significant others) a disservice by ignoring current urological practice. Dr. Welch is anti screening of all sorts as many of his books and papers show. However you have a nearby expert in prostate cancer Dr. Walsh at Johns Hopkins. What a diffence those two letters in a last name make! I challenge you to report Dr. Walsh's views and the basis for them -- it will hopefully make men think twice about rationalizing not being tested. Certainly no one should make a decision re treatment based on a PSA test and perhaps that is what they did in 1986. However, by 1997 when I was diagnosed things were much more nuanced. I learned of my options, the projections, the likelihood of invasive cancer (which were too high for me -- more than 30% at that time and likely to grow). So here it is 12 years later, 12 years that I didn't have to fight off an invading cancer. I know -- I'm an anecdote but so are many thousands of men who won't die from prostate cancer this year, and many ten's of thousands whose bodies won't be invaded by prostate cancer cells due to early intervention. You can avoid being overtreated by getting the data and the facts in your case, starting with a PSA (and the many related readings now made), and a relatively innocuous biopsy if necessary. Or you can play Russian roulette, avoid digital rectal exam and PSA stick your head in the sand and hope you are one of the majority of men who won't suffer from prostate cancer. But first ask yourself what odds of Russian Roulette would you play -- 1 bullet in 5 chambers -- the odds are your won't kill yourself but do you want to take the chance of being the 1 in 5 who will get invasive cancer? 1 in 10? what about 1 in 20? The odds of killing yourself from prostate cancer are in the range and many more who find out too late will undergo ongoing treatment for invasive prostate cancer -- and incurable disease that you will need to fight for the rest of your life. However, you can get a PSA test and avoid Russian Roulette by careful and rationale management of your results and condition, not illogically ignoring PSA it because it's too scary to know or a DRE because you don't like the feel of the Dr;s finger.

Posted by: rleesmith18 | September 3, 2009 4:02 PM | Report abuse

As several others have indicated, you leave out a lot by not mentioning the biopsies that follow a bad PSA reading.

Bad on ya.

Posted by: Bartolo1 | September 3, 2009 5:02 PM | Report abuse

My husband is just finishing up his proton radiation treatment at Loma Linda Medical University in CA. Our family physician found his prostate to be asymmetrical, told him to go to our urologist. His PSA was 4.0 up 2 pts from a yr ago. Nothing abnormal about that IF you relie on the PSA alone. However, his biopsy - 12 specimens taken - showed that he had cancer. Further bone scan and CT with dye showed that the cancer was totally in the prostate. HOWEVER HE STILL HAD CANCER. What so many urologist won't tell you is the success story of the proton treatment at Loma Linda. No radical surgery - the gold standard- no cryo, no seeds, no davinci robotic surgery. He will no longer have cancer. CANCER still kills. Prostate cancer is discovered in 1 out of 6 males - that is a given not just a statistic. IF A FAMILY MEMBER HAS BEEN DIAGNOSED WITH PROSTATE CANCER YOUR CHANCE OF HAVING IT HAS GREATLY INCREASED, almost 95%!!!!! My husband is the FIFTH cousin to have it on his mother's side of the family. This is very deep in that family. SHOULD YOU RECEIVE THE WORD THAT YOU HAVE PROSTATE CANCER YOU OWE IT TO YOURSELF TO INVESTIGATE ALL AVENUES OF TREATMENT. All urolosists are surgeons FIRST. They are only interested in the $$$$ you will put in their pockets. Our own urologist blew us off because we weren't going to do what he wanted us to do. In Canada and in Europe, if you are 55 YOU WON'T GET TREATED. IT IS A WATCH AND WAIT. Atleast still here in the US you men are getting the necessary treatment. YOU are in control of this decision. What we found out about all other options was terrifying. The seeds CAN dislodge and travel, causing death, YOU can transfer a seed to your spouse during intercourse' the cryo is the last option used if all others fail; radiacal is too invasive and you have to bank at least 4 pints of blood ahead of your surgery. Think I am kidding??? YOU do your research and talk to many many post treated survivors.

Posted by: rogerjan | September 3, 2009 6:01 PM | Report abuse

Recently advocates of health care reform have advocated more cancer screening to save money. But here we see that such screening wastes money. The Number To Treat is excessive and patients are not warned of the consequences. Of course, if you are afraid of breast cancer or prostate cancer, you can have the organs removed, then deal with it. But compare US with UK, death rates similar, much more screening in US, and many more "cancer survivors" impotent, incontinent, and scarred, with empty wallets. Please oppose such "reform."

Posted by: joeshuren1 | September 3, 2009 7:16 PM | Report abuse

Prostate Cancer "For Profit"

Screening, "early detection" and treatment of a "disease" that 100% of men will have if they live to be 100 is big business in this country. It has been commercialized by the widespread introduction and persistent use of an unproven test (PSA) to create a whole class of new "cancer" patients. The medical industrial complex's exploitation of prostate "cancer" fears rivals that of Bush's terrorism fear campaign. Fear sells ... and hospitals and doctors are getting rich pandering to it.

Choice is important in our for-profit medical system so all manner of equally unproven prostate cancer treatments are marketed like soft drinks to these newly created pseudo-patients (who are encouraged to choose their own poison)... each has their own profit-driven advocates within the system. All are debilitating in one way or another and they ruin many men's lives.

As is obvious from some of the comments here, the dumbed-down US population cannot comprehend the even the simple statistics behind the latest studies on screening. Somewhere between 20 and 48 men have to be treated to save one! And yet here we have the usual plethora of testimonials about how someone's particular PSA test and someone's particular treatment saved their particular life. Informed consent, though sadly lacking with respect to PSA testing and cancer treatment in this country, if it were offered, still requires a certain minimum level of intelligence and education.

In a different world, what all men will get if they live long enough, and will die with rather than from, would be called "Age-related prostate degeneration" (how about ARPD) -- something that has no relation at all to the real aggressive prostate cancer that kills relatively few -- and for which, as of today, there is no scientifically proven screen or test or cure.

Posted by: edwulet | September 3, 2009 7:36 PM | Report abuse

Hey edwulet, if you are male do us all a favor and never get your PSA checked.


==========================================


Prostate Cancer "For Profit"

Screening, "early detection" and treatment of a "disease" that 100% of men will have if they live to be 100 is big business in this country. It has been commercialized by the widespread introduction and persistent use of an unproven test (PSA) to create a whole class of new "cancer" patients. The medical industrial complex's exploitation of prostate "cancer" fears rivals that of Bush's terrorism fear campaign. Fear sells ... and hospitals and doctors are getting rich pandering to it.

Choice is important in our for-profit medical system so all manner of equally unproven prostate cancer treatments are marketed like soft drinks to these newly created pseudo-patients (who are encouraged to choose their own poison)... each has their own profit-driven advocates within the system. All are debilitating in one way or another and they ruin many men's lives.

As is obvious from some of the comments here, the dumbed-down US population cannot comprehend the even the simple statistics behind the latest studies on screening. Somewhere between 20 and 48 men have to be treated to save one! And yet here we have the usual plethora of testimonials about how someone's particular PSA test and someone's particular treatment saved their particular life. Informed consent, though sadly lacking with respect to PSA testing and cancer treatment in this country, if it were offered, still requires a certain minimum level of intelligence and education.

In a different world, what all men will get if they live long enough, and will die with rather than from, would be called "Age-related prostate degeneration" (how about ARPD) -- something that has no relation at all to the real aggressive prostate cancer that kills relatively few -- and for which, as of today, there is no scientifically proven screen or test or cure.


Posted by: edwulet | September 3, 2009 7:36 PM


Posted by: 12oreo | September 3, 2009 7:51 PM | Report abuse

From some of these posts one would never guess how many men die from prostate cancer each year. Interestingly the Europeans have just revised their conclusions and now report that PSA testing reduced deaths from prostate cancer by 30%, and I would imagine cases of invasive cancer by even more. Men who don't get PSA testing are playing Russian Roulette, and they don't have to play. By the way if we can't trust urologists, we can't trust radiologists, and we can't trust epidemiologists -- they are all fighting for more of the "pie". However there are probably a few honest sincere knowlegable MDs around so the trick is to find them.

Posted by: rleesmith18 | September 3, 2009 11:37 PM | Report abuse

Edwulet: I see you like to play Russian Roulette even if you think you have one chance in 20 of killing yourself. However you can get a much better estimate of the odds through PSA testing (including PSA velocity, density, etc) and a biopsy and reduce the odds to one in 5 or one in 3 by finding good urologicalconsults. You will never know for sure, but you can decide which you want to face, e.g. a 25% of dying from prostate cancer in the next 10 years, versus a 5% of upleasant side effects of a treatment that will rid you of cancer. You can see and understand the odds facing your as an individual, you can consider the risks, ask your wife how important your erections are, etc. Based on that, you can attempt to chart your life. Perhaps the folks I know who have chosen prostectomy’s are indeed dumbed down – but all I can say is one was Chair of the Math Department at a major research university, another Director of a Neuroscience program, two were successful lawyers, two PH D’s in engineering. They all had routine PSA screenings, followups, analysis of the situation, and chose life – with definite brief incoveniences but now leading happy lives free of recurrence or spread at the present time. I know, we are all anecdotes, but I chose to be an anecdote trying to chart the best personal course for myself then a nameless statistic subject to unknown doctors and treatments in a massive survey (and by the way the Europeans now admit that they got their statistics all wrong. Hopefully the Americans will soon as well since the “scientific study” was completely uncontrolled). As as far as proton radiation --- glad it was successful and definitely investigate all of the possibilities but don’t knock surgery – it holds the promise of getting out all of the cancerous cells which is what makes sense to many of us. Finally, Edwulet, rectal exams generally are done with the finger, not the head, so stop trying to practice medicine.

Posted by: rleesmith18 | September 4, 2009 3:36 PM | Report abuse

Here is a link to a recent summary on the role of vitamin D in prostate cancer:
http://archive.constantcontact.com/fs026/1102452079631/archive/1102585702876.html

Posted by: mbarnes012 | September 4, 2009 3:38 PM | Report abuse

Most patients are unaware that almost 20% of men who undergo surgical removal of the prostate will develop a condition known as Peyronies Disease. This condition, for which there is no satisfactory treatment, causes penile scar tissue, often makes sexual relations impossible and can be accompanied by excruciating pain.

When I developed this condition, I could never imagine that something like this could occur. I started a web site, www.curepeyronies.net and am amazed by how many men write me about their desperate situation. Urologists must inform all men considering prostate removal about this rather common side effect.

Posted by: curepeyronies | September 4, 2009 9:35 PM | Report abuse

What nonsense to hear that men are receiving unnecessary PSA tests. Without the PSA, I probably would be dead now. My father died of prostate cancer and believe me, it was not pleasant to watch. A PSA test is nothing more than a blood test. Then, if the result is too high or has risen too quickly, a biopsy is performed. The biopsy indicates whether there is cancer in the prostate or not. To say that prostate cancer grows so slowly that something else will kill you is scientific BS. Prostate cancer grows slowly except when it doesn't. We really have no way of predicting that other than a biopsy. At our present stage of knowledge, testing is the only hope we have against cancer. And because of inadequate tests, some cancers don't show their ugly faces until it's too late to do anything about them. A blood test is not a dangerous thing. It doesn't really hurt, even for people like me, who practically faint at the sight of blood. I think Dr. Welch's time could better be served working in a zoo. Andy Geller, journalist and prostate cancer patient.

Posted by: andygeller | September 6, 2009 6:34 PM | Report abuse

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