There’s a simple blood test done routinely to screen men for a condition that is rarely serious. But if your screening test happens to be positive, the resulting treatment and side effects are likely to be devastating to your day to day quality of life, and may include stress incontinence, overflow incontinence, urge incontinence, or continuous incontinence. And impotence, temporary or permanent.
Should you get this blood test done?
That’s the controversial question behind two large, randomized clinical trials this past year studying the relationship between PSA-based screening and prostate cancer mortality: The European Randomized Study of Screening for Prostate Cancer and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial in the U.S. According to the European study, which involved over 162,000 men between the ages of 50 and 74 in seven countries, PSA-based screening reduced the already low rate of death from prostate cancer by 20%, but was also associated with a high risk of overdiagnosis and overtreatment.
The American PLCO trial found the rate of death from prostate cancer was very low for both the 38,343 men in the group that received annual PSA-based screening and the 38,350 men in the control group who received “usual care.” The conclusion: “Screening was associated with no reduction in prostate cancer mortality.”
‘Non-intervention’ is what urologist Dr. Anthony Horan says he was taught when he attended medical school and also during his urology residency at the Columbia Presbyterian Hospital in New York in the mid-1970s. “We didn’t go looking for the incidental cancers that were of no clinical significance,” explains the author of The Big Scare: The Business of Prostate Cancer. “And if we found them, we did nothing about them.”
Dr. Horan says that this non-treatment approach came originally from a Mayo Clinic study that showed most men diagnosed with prostate cancer had a survival curve identical to the general population of men.
“That was the conventional wisdom of the 1960s, and it is still true today. During my 30+ years as a board-certified urologist, I’ve seen quite a bit of suffering, much of it needless, in my opinion. In my work both in private practice and with the Veterans Administration in California, I’ve encountered many men who’ve received treatment for prostate cancer that greatly diminished their quality of life and produced horrible side effects, but did absolutely nothing to prolong their lives.”
The American Cancer Society, the Canadian Task Force on Preventative Health, the National Cancer Institute, the US Preventative Services Task Force and the American Medical Association recommend against screening for the early detection of prostate cancer in healthy men without symptoms because of the lack of evidence at this time.
PSA, or prostate-specific antigen, is a protein produced by the prostate gland, blood levels of which generally rise when a prostate tumour is present. PSA blood tests can catch the cancer in its early stages, but can also produce false-positive results that result in devastating and unnecessary overtreatment.
prostate cancer cells
Normally, as men age, the walnut-sized prostate gland increases in size. If it grows large enough, it may press on the urethra, the tube that carries urine from the bladder. This may make the urine flow weaker or slower or make men have to urinate more often, especially at night. In the large majority of cases, an increase in the size of the prostate and a change in urine flow do not mean you have cancer – these are just a normal part of aging. Nonetheless, healthy men who experience symptoms should consult a physician.
“Serial PSA screening has at best a modest effect on prostate cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective, but whether it does more good than harm. For this reason, comparisons of the effectiveness of PSA screening with, for example, the similarly modest effectiveness of breast cancer screening cannot be made without simultaneously appreciating the much higher risks of overdiagnosis and overtreatment associated with PSA screening.”
Prostate cancer is a relatively common disease, with about 260,000 men over the age of 50 diagnosed each year in North America. But as daunting as that number may sound, Dr. Horan reminds us that prostate cancer is a very slow-moving disease.
“Estimates show that 94% of the cancers detected with the routine PSA blood test would not cause death before the age of 85. More men die in car accidents than of prostate cancer each year.
“The PSA is a test I have major qualms about and objections to. The PSA test has triggered an enormous number of expensive and unnecessary prostate biopsies, which have led to treatments, a rash of radiation and radical surgery injuries, and even death. After undergoing radiation, over 45% of men experience severe problems such as erectile dysfunction and incontinence. So this is an issue that not only impacts the lives of many men, but the lives of their significant others as well.”
Dr. Horan recalls that, starting in 1986, just after the PSA test was introduced, many physicians other than urologists started buying testing machines in order to do the tests in their offices. Following this, diagnoses of prostate cancer and its treatment rate started to soar. The biopsy rate quintupled and the number of men labeled prostate cancer victims doubled between 1989 and 1992.
“Despite this, statistics prove that no more cancers have been discovered since the introduction of the routine PSA test than would have been found in a random series of men the same age whose PSA is unknown. You can tell your doctor that you don’t want the PSA test. That’s your right. The only men who should be having the test are those at high risk or who’ve already been biopsied and diagnosed with prostate cancer.”
Despite growing evidence that PSA screening should not be routinely done, this road will not be an easy one for either patients or their doctors. As one physician commented in a prostate cancer online support community: “Many PSA tests are administered as yet another manifestation of defensive medicine. I think a physician could be successfully sued for failure to offer this test to men in a given age/risk group based on some previous guidelines. This should give some pause to those who think comparative effectiveness research is going to be simple. I am in favor of such research, but it will not be simple.”
See also: Prostate Cancer Over-diagnosed with PSA Test
This is an outstanding book, yet I fear its very thesis will frighten off men and their doctors. There is a very powerful lobbying faction out there snowballing out of control in an effort to raise awareness of this diagnosis and then the “need” for treatment. Thanks for helping to share the experts’ opinions of the other side of this issue.
Oh, yeah, it’s a business alright. And what a business! A license to print money for many doctors. I’ve read this book and I encourage everyone to read this – especially men who have bought into the growing demand for routine PSA testing (a movement largely funded by industry and for-profit medicine).
Thanks for helping to spread the word – it’s an uphill battle.
I absolutely agree with the Doctor who wrote this book, but my suspicion is that if a man hears the C-word, he is unlikely to tolerate cancer of any kind, no matter how benign, to go untreated inside his body.
Luiz, I’m betting you have never been diagnosed with cancer yourself. Let’s see how willing to do nothing you’d be if you were one day diagnosed or if you had symptoms consistent with prostate cancer. My guess is that both you and the guy who wrote this book would be demanding both the test and then immediate treatment.