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The Prostate War Continues

Published: October 12, 2011

In news sure to shake up the world of men’s health the US Preventative Services Task Force has firmly come down AGAINST the use of the PSA test to screen for prostate cancer.

The screening test has been argued about for years. A prostate specific antigen test has a profound weakness. It is not able to distinguish benign vs deadly forms of cancer. In other bad news for advocates of screening the USPSTF has noted that digital rectal exams and ultrasound examinations are also unreliable in diagnosing prostate cancer.

This argument hinges on the stats. While supporters of testing point out that lives CAN be saved when a dangerous cancer is located sooner rather than later – or so common sense would seem to dictate – the data does not seem to support the utility of the tests on two fronts.

First, the aggressive cancers, even when found earlier are so problematic that earlier discovery does not seem to make a big difference in their treatment. Second, treatment of slow growing types of prostate cancers may do as much (or more) harm as they help, especially since many older men with slower cancers never suffer harm from their disease.

Given the data from five well-controlled clinical trials the Task Force elected to come down firmly against testing. When the USPSTF came down against women in their 40s receiving mammograms two years ago a firestorm of controversy was unleashed. This move seems sure to do likewise.

The biology of prostate cancer is curious in that one third of men between 40 and 60 apparently have some form of the disease. By age 85 the vast majority of men have it, but in most instances its benign nature means that it has no impact on their mortality. As such screening men over 70 has been long recognized as least valuable. Older men have the least chance of meaningful improvement from treatment, while sustaining all the usual negative effects associated with such treatments.

A biopsy of the prostate, the logical next step after finding an elevated PSA is not without problems. The multiple core samples retrieved from the gland can involve damage to nerves which can contribute to erectile dysfunction. We have long been aware of this in my ED clinic. While the injury to the nerves may heal completely they may not. Even if they do, it may take months. And any surgery to the prostate, even the “nerve sparing” types are very likely to cause injury to local nerves.

No surgery is 100% safe, of course. It is estimated that up to 70,000 men suffered serious complications to surgical or radiation therapy between 1986 and 2005 (and at least 5,000 died). This is by-the-way out of 1 million men who received radiation, surgery or both. The numbers associated with erectile dysfunction and/or urinary incontinence are fairly startling. During that same time frame it is estimated that 200,000 to 300,000 suffered either or both, and I suspect those are very conservative numbers.

In addition to surgery and radiation there are several pharmaceutical agents used to battle prostate cancer by blocking male hormones. While they have notable side effects (erectile dysfunction again, also hot flashed and breast enlargement) they have not proven to be especially helpful treatments. This failure has also been noted in these recent studies. Given the fact that treating people with high PSAs is a lucrative business there is bound to be some push-back from many doctors and drug companies. And in many cases their objections may not be rooted in mere avarice.

In some cases it might be possible to find a cancer early (thanks to PSA tests and screening digital rectal exams) that is localized and thus surgically curable. It is hard to justify not doing the screening given the reality of such cases, but in the end one has to look at what actions will generate the greatest good for the greatest number.

The data supporting the benefits of routine prostate tests remains surprisingly weak. This is why the USPSTF has acted as it has. We will re-visit this topic after