Is Routine Screening For Prostate Cancer Necessary?
A government panel, the United States Preventive Services Task Force, said on Thursday that men 50 and over should no longer have routine P.S.A. screening for prostate cancer, based on the findings of five well-controlled clinical trial studies. The test, says the panel, does not save lives and has led to men taking more tests and undergoing treatments that have caused pain, impotence and incontinence in many.
Given that there are 44 million men over 50 in the US and that over 33 million have had the P.S.A. test (which measures a protein — prostate-specific antigen — released by prostate cells) the new recommendation could have wide repercussions for men’s health. Could it be possible that tens of thousands of men have undergone medical procedures that have done them more harm than good, and that doctors — urologists in particular — have been routinely prescribing treatments that have turned out to be unnecessary?
New Clinical Trials
The stakes are high. One in six men in the US will eventually be diagnosed with prostate cancer. An estimated 32,050 men died of the disease last year, with most deaths occurring after the age of 75; the disease is not common in men under the age of 50. However, autopsy studies reveal that a third of men aged 40 to 60 have prostate cancer, three-fourths after the age of 85.
The largest of the new clinical trials about prostate screening showed that “if any benefit does exist, it is very small after 10 years.”
The European trial had 182,000 men from seven countries who either got P.S.A. testing or did not. When measured across all of the men in the study, P.S.A. testing did not cut death rates in nine years of follow-up. But in men ages 55 to 69, there was a very slight improvement in mortality. The American trial, with 76,693 men, found that P.S.A. testing did not cut death rates after 10 years.
The rise in P.S.A. testing has led to a rise in biopsies and treatments, including some that have led to other health problems for many men:
From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, the man who developed the test, Dr. Richard J. Ablin, has called its widespread use a “public health disaster.”
Two years ago, the same government task force caused an uproar when it recommended that women over 40 no longer needed to have routine mammograms. Mindful of the potential controversy, the panel delayed releasing the recommendation about prostate screening for two years, until the upcoming week. Dr. Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chairwoman of the task force, explained:
“Unfortunately, the evidence now shows that this test does not save men’s lives. This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”
Advocates for routine prostate cancer screening — including Major League Baseball Joe Torre, former New York City mayor Rudolph W. Giuliani and advocacy groups such as Us TOO — as well as urologists are preparing to fight the recommendation. The drug business will also be stepping into the fray, treatment for prostate cancer being a “lucrative business.” In addition, the task force’s recommendations could play a significant role in determining whether the P.S.A. test is fully covered by private health plans as envisioned under the health reform law and also under government federal health programs such as Medicare (though, currently, Medicare is required under law to pay for the test, no matter what the task force recommends.)
Would it be better to use the current test despite the findings of the government panel, until a better test is developed? Or has widespread screening for prostate cancer caused more problems than benefits?
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