Prostate screening: yes or no?

There’s a big debate over the value of PSA testing, which refers to tests for prostate-specific antigen, a protein produced by cells in the prostate gland. It’s present in small quantities in the blood of normal men and is often elevated in men with prostate cancer and other prostate disorders. But other conditions can also cause an elevated rate. The annual bill for PSA screening is at least $3 billion, much of it paid for by Medicare and the Veterans Administration

Prostate screening is now out of favor. In 2012, the US Preventive Services task Force recommended against routine screening, having found that the benefits do not outweigh the risks, which include a high rate of false positives. Men with false positives undergo painful biopsies that found no cancer. And even when a biopsy finds cancer, there is no way to know if it's aggressive or slow growing, in which case it would never be a problem. Autopsy studies have shown that approximately one third of men aged 40 to 60 years have the slow-growing prostate cancer; for men older than 85, the proportion is three-fourths. In other words, the men die with the cancer, not because of it.

The risks of surgery to remove the prostate include death, urinary incontinence, impotence, and bowel dysfunction. What’s more, the two largest studies of screening produced contradictory results; one showed a slight decrease in prostate-cancer-related deaths and the other showed no advantage. Both tests were found to be flawed.

The most outspoken critic of the tests is Dr. Richard J. Ablin, who says he “discovered the prostate-specific antigen, or PSA, which is now the most widely used tool in prostate screening.” It turns out that, while he did discover an antigen in the normal prostate, he neither developed the PSA test nor discovered the PSA on which the current test is based. That credit goes to cancer researcher T. Ming Chu. That factoid is neither here nor there, although Ablin gets a lot of press. He fiercely maintains that “testing should absolutely not be deployed to screen the entire population of men over the age of 50,” and that the test is still used because “drug companies continue peddling the tests and advocacy groups push “prostate cancer awareness by encouraging men to get screened.” He's probably right about that.

Recently, in an op-ed article called “Bring Back ProstateScreening,” Dr. Deepak A. Kapoor argues that prostate screening tests are now more refined than in the past and take into account age, race, the size of the prostate, how fast PSA levels rise over time, and how PSA circulates in the blood stream. Plus doctors can add other analyses including the presence of certain genes and M.R.I images. He strongly recommends that men get a baseline PSA test in their 40s, then participate in a “personalized screening regimen that considers risk factors and other indicators.”

I don’t know, if I were a man, I’d just forget it.

Update: new diagnostic tools.

Next week: Osteoporosis--maybe not worth worrying about

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