</em> will not cause problems if left alone in most, but not all, asymptomatic men whose tumors are found after a screening test. )
SLOW GROWING: Prostate cancer cells (shown in a color-enhanced scanning electron micrograph) will not cause problems if left alone in most, but not all, asymptomatic men whose tumors are found after a screening test.
Image: Parviz M. Pour/Photo Researchers Inc.
In Brief
- Studies show that use of a blood test to screen for prostate cancer does not greatly decrease the risk of death.
- Hundreds of thousands of men have likely suffered severe side effects as a result of unnecessary treatment.
- Yet many physicians and professional medical societies believe that widespread screening saves lives.
- Screening for prostate cancer but delaying treatment in most cases may prove to be an effective compromise.
Last fall the U.S. Preventive Services Task Force dropped a bombshell, arguing that healthy men should stop undergoing a routine blood test as a screen for prostate cancer. An analysis of the best available evidence, it argued, had shown little or no long-term benefit from the measure—called the prostate-specific antigen (PSA) test—for most men with no symptoms of the disease. Use of the screening was not saving lives. In fact, it was needlessly exposing hundreds of thousands of men who were tested and found to have prostate cancer to such common complications as impotence and urinary incontinence (from surgical removal of the prostate) and rectal bleeding (from radiation treatment). Indeed, the task force estimated that more than one million men have been treated because of PSA testing who otherwise would not have been since 1985. At least 5,000 of them died soon after treatment, and another 300,000 men suffered impotence or incontinence, or both. Instead of praise for sparing more men from suffering similar fates, however, the task force’s announcement quickly drew outrage and counterarguments from several professional medical groups, including the American Urological Association.
The controversy is not new. Experts have long debated the value of the PSA test, but until now the weight of opinion in the U.S. fell on the side of doing the test. As a medical oncologist specializing in prostate cancer, however, I essentially agree with the task force’s assessment of the evidence. Most people outside the medical community do not realize how flimsy the evidence has been in favor of the screening tests. (Make no mistake, the PSA test still provides valuable information after a prostate cancer has already been diagnosed, however.) Nor does the public realize how common complications can be—even from sophisticated treatment that proponents advertise as the most advanced.
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22 Comments
Add CommentThis article presents multiple opinions and varied research results, but the headline is misleading and dangerous. Any man reading just the headline could dismiss the PSA test out of hand which could cost him his life.
Reply | Report Abuse | Link to thisStan Rosenfeld
12 Rally Court
Fairfax, CA 94930
415 459-4668
I agree with the commenter Mr. Rosenfeld about the sensationalistic headline. Also, the article does not state how many men died every year in the United States from prostate cancer (it's too hard to tell from the graph) and how that number compares with deaths from other cancers and other causes. That information would have been helpful to gain perspective.
Reply | Report Abuse | Link to thisThe USPSTF has only verified what we as physicians have known for years. The PSA was released for use long before any real data was available to show it was effective in reducing death rates from prostate cancer. After more than two decades the best studies show that the PSA has done little to reduce the death rate from prostate cancer and may in fact be causing more harm than good. The USPSTF recommendation was long overdue and I applaud their courage for making it in a political climate where the media and special interests were bound to skewer them for it.
Reply | Report Abuse | Link to thisDr. Garnick's article gives a misleading interpretation of the statistical evidence on prostate cancer screening. First, he emphasizes that both the European and U.S. screening studies find no "statistically significant" differences in overall death rates between the screening group and the control group. What he fails to note is that a standard power analysis shows that to detect a plausible effect of prostate cancer screening on overall death rates would require a study with a sample size of several million men, far larger than the two studies in question, and far larger than any plausible study. Therefore, it is almost impossible for these studies to provide any relevant evidence on prostate cancer's effects on overall death rates. Second, he emphasizes the European study's result that for every 48 men treated as a result of screening, only one prostate cancer death was averted. He interprets this as meaning that 47 men were treated unnecessarily. But the European study's finding of a "number needed to treat" (NNT) of 48 is as of an average follow-up in the sample of 9 years after the study began. Given that prostate cancer develops slowly, the prostate cancer death rate in the screened and control groups only begins to diverge as of 7 years after the study began. More recent analysis suggest that the NNT is 18 as of 12 years after screening began. It is unclear what happens after 12 years, because of insufficient sample size, but it is quite possible that the screening vs. control group differences will continue to grow. This makes the choice of whether to screen or not harder to make. Treatment that results from screening may reduce a man's risk of dying from prostate cancer by 5% (1 in 18) as of 12 years after screening has begun, and maybe by more later. But there is a 50% chance of serious side-effects. Not an easy choice, either for individual men or society. But it is certainly not the case, as the article's subtitle says, that "evidence shows that screening does more harm than good". The evidence is far more ambiguous than implied by either that subtitle, or by the article's content.
Reply | Report Abuse | Link to thisThis article, the USPSTF recommendation and the recent NIH statement that most prostate cancer shouldn't be even be called "cancer" is a lot more than long overdue. A Stanford M.D. and Professor of medical ethics attempted to warn doctors in 1996 in a great article "The Great American Pseudo-epidemic of Cancer of the Prostate." (Google and read in cache as they have recently removed the article from the medical journal website)
Reply | Report Abuse | Link to thisFrom a personal perspective - my father had a high PSA test when he was 75 and was so scared of the word "cancer" because my Mom had just died 6 months after she was diagnosed with lung cancer (and the decline was not pretty to watch) that he ignored the fact that he was probably going to pass away from something else than prostate cancer. He died 10 years later from complications due to heart failure. He had radiation treatment and his last years afterwards were miserable due both to incontinence and impotence. I think it's one thing to get this diagnosis at 55 and another at 75 and this recommendation is long overdue. Quality of life is just as important as treatment from my perspective. I say this as a person who had a biopsy for suspected thyroid cancer at 47, had half my thyroid removed and then a negative post-surgical biopsy. After that experience, I would be damned leery of getting treatment for a high PSA unless the diagnosis was better defined.
Reply | Report Abuse | Link to this"Instead of praise for sparing more men from suffering similar fates, however, the task force’s announcement quickly drew outrage and counterarguments from several professional medical groups, including the American Urological Association."
Reply | Report Abuse | Link to thisLikely they did not want to lose their "cash cow" (The windfall they recieve from unnecessary testing and procedures).
The subject of intervention or tumour removal is discussed in this article by microbiologist Walter Last: http://www.health-science-spirit.com/pleomorphics.htm. If pleomorphic microbes are the hidden agent of cancer and autoimmune diseases then we should be more vigilant to their devious ways.
Reply | Report Abuse | Link to thisLast also points the blame for sudden origins of Lyme's and AIDS, etc, as military bio labs, playing pleomorphics.
My prostate has already suffered the 12 needle biopsy. The next grid test (if it happens) is 50 points. I wonder if that could precipitate spread..?
As the editor of this feature, I asked Dr Garnick to respond to the above comments. Scroll down to read his replies. CG.
Reply | Report Abuse | Link to thisDr. Garnick responds:
I am so pleased by the voluminous responses to this very important topic and will address the key aspects of the respondents’ comments.
Mr Rosenfeld and Maglatyj imply that the headline that accompanies the article is misleading, dangerous and sensationalistic. Please recognize that the essence of the headline succinctly states the key findings of the Task Force’s deliberations and summarizes the key points. There were no reasonable alternatives and the headline in essence provided the impetus for the article. The “What’s next” addendum provides a segway into the complexities and areas that the readership is able to enter and navigate. It would have been wonderful if a more positive spin on screening could have been the headline, but until such data emerge to justify an optimistic spin, the current one is truthful and to the point.
As the editor of this feature, I asked Dr Garnick to respond to the above comments. Scroll down to read his replies. CG.
Reply | Report Abuse | Link to thisDr. Garnick responds:
DrM, EJDwulet, Scrat and cdmgsdad all bring varying degrees of endorsement of the Task Force’s findings, each with a slight different perspective. Collectively, the embrace the key aspects of the findings—that despite the widespread use of PSA testing and the downstream biopsies and treatments, deaths have not been avoided and side effects of such an approach do indeed alter the quality of a man’s life without providing an accompanying benefit. Attention is again paid to the nomenclature surrounding prostate cancer terminologies and we as well as others have discussed whether a less threatening term could be used for low grade low stage cancers which are often the ones inappropriately treated. More discussion is needed surrounding this point and will require the active participation of clinicians, pathologists and molecular geneticists.
As the editor of this feature, I asked Dr Garnick to respond to the above comments. Scroll down to read his replies. CG.
Reply | Report Abuse | Link to thisDr. Garnick responds:
Scrat hits the nail on the head, not only by recounting (his/her) own experience with undergoing a hemithyroidectomy (removal of half the thyroid gland) for suspected cancer that turned out not to be the case, but also emphasizing the morbidity of (his/her) father who was treated for prostate cancer at age 75, then experienced the debilitation side effects of impotence and incontinence and then dies in the interim from heart failure. While we cannot say unequivocally that the prostate cancer treatment provided no benefit, more likely than not, the competing causes of death, especially for a 75 year old were greater than any potential problems that an untreated and undiagnosed prostate cancer would have caused.
As the editor of this feature, I asked Dr Garnick to respond to the above comments. Scroll down to read his replies. CG.
Reply | Report Abuse | Link to thisDr. Garnick responds:
Cdmgsdad touches on the darker side of the medical profession where some claim that procedures and testing have in part a financial motive. There is no question that widespread PSA testing and all of the downstream tests and procedures are a major source of expense for the health-care system and revenues for physicians; the use of these tests should be hopefully dictated by solid clinical evidence and not profit motives. One would hope that with the new Task Force guidelines, the over-utilization of prostate testing and associated procedure utilization will diminish. Time will tell.
I've had two Urologists explain to me in the last month that in my case I would have greatly benefited from regular PSA tests. Unfortunately, I listened to the propaganda and now it may cost me my life as my prostate cancer has gone metastatic.
Reply | Report Abuse | Link to thisI applaud the USPSTF comments. We have known for some time that PSA blood test is not a wonderful screening when applied to healthy men. This single test simply lacks the ability to accurately discriminate low grade tumours from aggressive ones. As we are learning with other cancers, prostate cancer is a quite heterogeneous disease. Clearly, better biomarkers are needed, and, encouragingly, some progress along this line is being made. In the meantime, we have to accept the profound limitations of PSA. Continue scrrening, but delaying treatment in most cases, is a good compromise.
Reply | Report Abuse | Link to thisI appreciate that Dr. Garnick has responded to some of the comments. However, there is no response to my comment that the existing studies, and any feasible study, lack adequate statistical power to tell anything about the effects of PSA screening on overall mortality. The samples are big enough to tell us whether PSA screening affects prostate cancer mortality, but not overall mortality. Therefore, it is inappropriate for the article, and the subsequent question and answer session, to put any stress on the finding from the various studies of no statistically significant effects on overall mortality.
Reply | Report Abuse | Link to thisBeyond PSA and Gleason: Focus on DNA
Reply | Report Abuse | Link to thisLacking molecular markers or other biomarkers reliable enough to predict the behaviour of individual patient's prostate cancer, the tumour-DNA may merit closer attention.
The problem with the Gleason score is it´s below 50 % interobserver reproducibility, thus rendering it a less than objective grading. (Burchardt et al., 2008 ) Differentiating dangerous cancers from others may be achieved by looking at complementary markers capable of specifying the risk of tumor-progression in individual patients.
The DNA-grading of malignancy is such a method if routinely added to amend the Gleason score. Over 40% of all prostate cancers are low proliferation DNA-diploid Type A (Engelhardt, 2012), qualifying to be
included in the AS (Active Surveillance) strategy. This alternative to invasive treatment includes regular PSA -
(dynamics) control, digital rectal examinations and control biopsies. DNA -tetraploid, x-ploid and multiploid micro-carcinomas would indicate the need for therapy.
27 scientific articles have so far been published supporting the use of DNA grading for objective and more reproducible diagnosis. DNA-grading of malignancy should routinely be added to the Gleason score. The two German pathology societies - Deutsche Gesellschaft für Pathologie (DGP) and the Bundesverband Deutscher Pathologen (BDP) - already recommend that DNA-grading by cytometric investigation and evaluation may be performed in addition to the Gleason-Grading in cases of Active Surveillance. In a prospective cohort study of 280 patients this approach is currently being further investigated.
Also, diagnostic use of DNA image cytometry in cervical / oral squamous intraepithelial lesions and other invasive carcinomas has been researched extensively at the University Institute of Cytopathology in Dusseldorf/Germany. The clinical application algorithms, hardware and software have continuously been re-evaluated and adapted into a commercially available system enhancing cancer diagnostics such as in prostate and oral cancers on the best available evidence and least overall cost for any health system.
My assessment of this article (read this week on return from hospital for prostate biopsy!) suggests the following:
Reply | Report Abuse | Link to thisIf biopsy is positive, a description of the histological appearance is important.
If high levels of mitosis are present, go on to treatment and take the risks.
If low level activity is found, embark on active surveillance doing regular PSA and if any dramatic change occurs - either repeat the biopsy, or go on to treatment and take the risks.
Would this be a rational approach in the current state of knowledge?
To the Editors,
Reply | Report Abuse | Link to thisI was very pleased to see Scientific American cover the data showing that prostate cancer screening has been shown to be harmful (February 2012). However, I have concerns about the article that relate, ultimately, to the way in which SA handles scientific topics.
The prostate cancer story offers important (and ulltimately sad) lessons to physicians, For nearly two decades physicians promoted a screening test that must have harmed tens of thousands of men. This should give us pause to ask why. Dr. Garnick attributes this failure to "a mistaken idea of how prostate cancer behaves over time." But while we may not have known how prostate cancer behaves, we have had a very good idea of how to evaluate screening tests since the early 1990's. PSA, sadly, was sold to men around the world without any evidence to show that it was beneficial. It just seemed like a good idea at the time. The false promotion was certainly driven - in no small part - by the enormous financial interests involved.
I am concerned that Scientific American's gave Dr. Garnick the opportunity to promote his own approach - which does not, in fact, abandon prostate cancer screening (as suggested by the evidence) but substitutes watchful waiting for aggresive treatment. Is this approach evidence-based or is this just another "good idea"? I believe that a careful peer review of Dr. Garnick's paper would have questioned the publication of this approach without support for its efficacy. Why, I wondered, was SA publishing an article which seems in direct contradiction to National Guidelines?
The Dana Farber website notes that Dr. Garnick "is Chief Medical Officer and the Executive Vice President of PRAECIS Pharmaceuticals" a company that produces prostate cancer treatments. SA saw fit to inform its readers that Garnick was associated with Harvard. Why was his direct involvement in the pharmaceutical industry not germane?
Peer review and open declarations of conflicts of interest should be standards in scientific literature. Otherwise, we just have the credibility of the journal. This article puts the credibility of SA in question.
Sincerely,
Matt Anderson, MD
Family Physician
Bronx, New York
The article by Dr. Garnick soft-pedals the real implication of the article, which is not just to vilify the PSA test, but to undermine the credibility of surgical methodologies. This has real political ramifications, especially in an economic environment where the imperative of “evidence-based” care is the rallying cry of medical insurers, who are just waiting to seize upon any excuse to deny health benefits. And since we’re on the subject of evidence-based science, it’s always important for an author to make full disclosure of any conflicts of interest. Dr. Garnick might have mentioned his position as a medical oncologist and his position as Chief Medical Officer and Executive Vice President of PRAECIS Pharmaceuticals, Inc. The potential for bias in this article should be viewed in this context.
Reply | Report Abuse | Link to thisThe article by Dr. Garnick soft-pedals the real implication of the article, which is not just to vilify the PSA test, but to undermine the credibility of surgical methodologies. This has real political ramifications, especially in an economic environment where the imperative of “evidence-based” care is the rallying cry of medical insurers, who are just waiting to seize upon any excuse to deny health benefits. And since we’re on the subject of evidence-based science, it’s always important for an author to make full disclosure of any conflicts of interest. Dr. Garnick might have mentioned his position as a medical oncologist and his position as Chief Medical Officer and Executive Vice President of PRAECIS Pharmaceuticals, Inc. The potential for bias in this article should be viewed in this context.
Reply | Report Abuse | Link to thisMark Bornfeld DDS
Brooklyn, NY
I read this article with deep personal interest, and admiration for Mr. H.
Reply | Report Abuse | Link to thisIt mentions that out of more than a million men treated since 1985 as a result of PSA testing, 300,000 suffered impotence or incontinence or both. These data must be difficult to obtain given our health privacy laws. My own experience at least suggests that this could be a considerable underestimate.
I was diagnosed with prostate cancer in 2003 at age 68 by digital rectal examination, despite a low-normal PSA (1.6). Two of seven specimens were positive with an intermediate Gleason score (7), a measure of the apparent aggressiveness of the cancer cells as viewed under the microscope by the pathologist. It should be noted that pathologists have gradually been increasing the Gleason scores they assign, so that it is now rare to see a reading less than “intermediate”. Like Mr. H. I was skeptical but 3 separate urologists recommended surgery, although only the first surgeon was able to feel a nodule. Mindful of Warren Buffet's dictum about the barber and the haircut, I consulted a leading urologic oncologist in my area. The pathology department at his hospital confirmed the Gleason score, and the oncologist too advised surgery.
A former colleague told me about a local urologist who had developed a robotic procedure, and when I visited him he provided publications showing relatively low percentages of impotence and incontinence. At the time I was vigorously active and healthy. I underwent the robotic procedure in March 2004 and have never felt well again. I am impotent, incontinent and have chronic abdominal pain. I complained of these problems at each postoperative visit in the first year and even exchanged emails with the surgeon about the abdominal pain. Nevertheless, my computerized medical record, to which I have access as a physician at another hospital in the system, specifically denies incontinence, and makes no mention at all of abdominal pain. Oh and by the way, the Gleason score at my surgery was lower (6), low enough that the lymph node biopsies performed during surgery and that have caused my leg swelling were also unnecessary. Only later did I learn of the "upgrading" of Gleason scores that has contributed to this epidemic of overtreatment.
This should not be surprising given the amount of money generated by this procedure. The hospital at which I had the robotic surgery continues to advertise it as having fewer complications as recently as last month in their insert in my local newspaper. The stock of the robot's manufacturer is up some 28-fold since my surgery. And one can be certain that surgeons and others are profiting from that rise not only as shareowners but also as consultants of various type.
I can't help thinking of my father, who had a sky high PSA (48) and a rock hard prostate in his middle 90’s but was never biopsied or treated, and died of unrelated causes at age 98.
I agree that the article is misleading. The October 2011 update indicates results far more equivocal than the author indicates.I suggest that those readers who are health professionals and/or are qualified to critically review the results of research should read the actual document, and not another health professional's interpretation.
Reply | Report Abuse | Link to thishttp://www.ncbi.nlm.nih.gov/books/NBK82303/
http://www.ncbi.nlm.nih.gov/books/NBK82311/#ch3.s1