With Prostate-Specific Antigen (PSA) Screening Questioned, Why Not Hurl Out the Next Unproven Prostate Tests?

The headline in the New York Times story this morning, “New Prostate Cancer Tests Could Reduce False Alarms,” by Andrew Pollack, had me scratching my head. Had I missed something in the story of advances in prostate cancer screening and diagnosis? The search for finding something better than PSA tests to reduce false positives and unnecessary biopsies has been going on for time immemorial, or more accurately, maybe the last 15 years. Also, separating the lethal from the cancers that amount to no trouble at all has also been a key research question.

Had The Times been bamboozled into a story by industry copywriters and urologists, hoping to bring back attention to the prostate? Clearly, the US Preventive Services Task Force, the American Cancer Society, and other groups stomped on routine prostate screening. Plenty of thought leaders agreed it is not a good prostate cancer screening test.

It’s also not just screening of asymptomatic men that is at issue. What about the men diagnosed with prostate cancer? Can they be better stratified so that men with lethal cancers are separated from those that require no treatment?

The New York Times article waxes poetic about the “more than a dozen companies that have introduced tests or are planning to in the near future.” It moves on to the transformative potential of molecular markers and a high-stakes battle looming ahead between Genomic Health and Myriad Genetics.

Are readers supposed to be wowed? I think so.

My favorite line in the story was this one:

“Some experts say that even if the new tests are not perfect, they are better than what is available now.”

Was The Times in the dark about thought leaders who thought all this is premature, urologic oncologists included? Apparently. Will more men and their loved ones insist on these unproven tests? Most likely.

I don’t dispute that we need a good test that separates the bad cancers, but the test is not here yet. The data is thin.

Mental Health and the Patient Point of View:
More High-Quality Stories Needed

I am thrilled that later today, Martha Roberts’ post on her own experience taking medication for mental illness, will run here. I first came across her post through a tweet from Ben Goldacre, author of Bad Pharma. It’s nice to know that he has not oversimplified the “bad pharma” argument into this meme: all drugs are inevitably bad for mental illness, overused, and inappropriate. Yes, there are huge problems with selective publishing of clinical trials data, withholding negative drug trials, and more. But mental health and mental illness are a lot more nuanced than a simple meme.

A lot more ink needs to be written about mental illnesses from the patient point of view, that show the real-life hurdles of people unfairly stigmatized, unemployed, or under-employed. I hope that this upcoming post (I’ll link to it here) is the first of many more.

If you have something to say about this, use the comments, or if you have a longer contribution, email me at patientpov “at” gmail dot com.

What’s Next for Prostate Cancer Screening and Treatment?

Complex medical stories require time and energy to tell, talk about, and think about. When stories involve yanking a test or practice that is widely used, all hell breaks lose. That’s why I am grateful to appear today on Alaska Public Radio Station KSKA, Anchorage, Alaska, on an hourlong Line One program on Prostate Cancer Screening and Treatment today. Thank you, Dr. Thad Woodard, the Line One host.

At issue, the latest US Preventive Services Task Force conclusion on the benefits and harms of prostate cancer screening:

“Prostate-specific-antigen-based screening results in small or no reduction in prostate-cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary.”.

What sounds like a seachange in practice merits some further analysis:

Did you know that PSA screening, defined as testing asymptomatic men with a PSA test, was adopted in the United States widely, and before it was tested in clinical trials? Screening recommendations for and against prostate cancer screening vary widely around the world.

From the late 1980s, PSA testing emerged and was presented as a wonderful new biomarker that could save men from dying of prostate cancer.

Soon, we saw a rising incidence of prostate cancer, detected by PSA. These men lived longer ostensibly with PSA-detected prostate cancer…but was it really clinically significant prostate cancer that would interfere with a  man’s life, kill him, or do we know enough?

Radical prostatectomies, minimally invasive prostatectomies (nerve-sparing, robotic) proliferated, as did similar trends in radiation therapy.

Eventually, news came out that maybe the treatments are worse than the disease. Quality of life outcomes pointed to impotence, urinary incontinence, and bowel problems.  The question also emerged  as to whether men’s lives were really extended.

Curiously, prostate cancer screening has not been embraced in many countries outside of the United States simply because the yield, number of lives saved is not viewed as compelling and the harms are substantial (overdiagnosis, overtreatment, impotence, urinary incontinence, bowel problems). Countries more committed to clinical trials did not recommend for prostate cancer screening.

In 2001, the UK, the ProtecT trial set out to evaluate the effectiveness of treatment for clinically localized prostate cancer, randomizing men to three treatments: active monitoring, radical prostatectomy, and radical radiotherapy.  This kind of trial could never have happened in the US, where treatment is embraced so strongly that it would be seen as unethical to randomize men to active monitoring (not watchful waiting, but much better- hence active). Interestingly, though, when ProtecT started, the investigators had trouble enrolling men because many men feared being randomized to one of the treatment arms and actually preferred active monitoring. Now that’s really different from what happens in the US.

Plenty of cultures wince at the thought of aggressive treatment for anything, be it cancer or other conditions. Readers might be interested in taking a look at the late Lynn Payer’s book, Medicine and CulturePayer’s work was eye-opening and might give patients confidence in trusting their point of view on how they want to work with physicians.

There is plenty of backstory to the way prostate cancer screening and treatment evolved in the United States. I hope to delve more into on the show tonight.

My own biases are closer to where the US Preventive Services Task Force is on screening.  But I’d like to hear from patients and men who have looked at the data.  I don’t think it is a black-and-white issue. Hoping you’ll tune in to hear me in less than an hour on Alaska Public Radio’s Line One. It will be streaming on your computer. (link is above). As always, I welcome your comments below.