Experts question prostate screenings, but men, doctors may reject advice

That was the reaction from many men last week after a top-level task force bucked two decades of medical practice and recommended against routine use of a common blood test to check for prostate cancer.

The PSA test does more harm than good, the group said. It pointed to two huge, expensive studies, which involved 259,000 men in the United States and Europe, that found that routine PSA testing of healthy men saved, at best, one life per thousand. And the tests drove many men to get expensive treatment — surgery, radiation, chemotherapy — they didn’t need. That’s the harm part.

The recommendation came from the U.S. Preventive Services Task Force, which in 2009 sparked an ever bigger storm by throwing doubt on the value of routine mammograms, especially for women in their 40s.

In both cases, the strong reactions stem from a fundamental divide between personal experiences with cancer screening and the statistical realities revealed by large studies.

“THE PSA TESTS SAVED MY LIFE!!!” one man wrote in an email to The Washington Post, calling the government task force a “death panel.”

He was expressing a cancer narrative that runs strong in our culture. It goes like this: I got a cancer test. It showed a suspicious result. A biopsy (which snips out a bit of tissue) then revealed that I had cancer. I chose treatment. Surgery, radiation or chemotherapy got rid of the cancer. I’m cured now.

The test saved my life.

Well, maybe.

With prostate cancer, there’s a problem with that story: There’s often no way to know if a particular case would have been fatal if left untreated. That is, it’s impossible to know if the treatment really cured you — or if you would have lived a long life without it.

It’s an unsatisfying — and confusing — reality of prostate cancer.

As Washington Post medical writer David Brown reported last year, about 240,000 American men receive diagnoses of prostate cancer annually. But in more than half of those cases — about 130,000 — the tumors are localized and low-risk. That means the tumor is confined to the prostate and is growing slowly.

In December, a group of experts appointed by the National Institutes of Health recommended that men with this form of prostate cancer forgo immediate treatment. (This NIH panel also debated whether it was time to stop calling such tumors “cancer.”) Keep an eye on it, they said, with regular doctor visits and tests. But don’t immediately rush to have your prostate removed, which can cause incontinence, impotence and, in rare cases, infections and dangerous blood clots.

But because these low-risk cases are called “cancer,” the natural reaction, instead, is this: Get it out. Operate. Give me radiation. Cure me.

Urologists, oncologists and surgeons offer these options to patients with even the lowest-risk tumors. They treat cancer for a living, so they tend to err on the side of giving treatment.

As a result, about 90 percent of men with the low-risk prostate tumors opt for treatment.

No one says: I got a PSA test. It was high, so I got a biopsy. The biopsy caused pain for weeks and made me bleed. But I didn’t have cancer. Good thing I got that test.

No one says: I got a PSA test. It was high, so I got a biopsy that showed I had a small, low-risk tumor. I got surgery. Now I wear a diaper and can’t make love to my wife. And I wonder if I really needed to go through all that.

Instead, the triumphal narrative tends to be what most people hear: I did something. And now I’m cured.

It’s an affirmative message. It reinforces the idea that screening saves lives.

The problem with the PSA test is that it doesn’t detect cancer, and so it’s not a good way to screen the entire population. The test measures prostate-specific antigen, a substance made by the prostate even when that male gland is healthy. Infections, benign enlargement of the gland, drugs such as ibuprofen and even having sex can — along with cancer — lead to a high PSA reading.

Yes, the tests do save some lives, the task force said — zero to one per 1,000 men, according to the U.S. and European studies, which lasted 15 years. And that one life could be yours. That’s why the recommendation against regular PSA testing can be hard to accept.

If there were no downside to the test, no cost to society in the form of expensive biopsies and treatment that most men don’t really need, it would make sense to keep giving it to every middle-aged man. But that’s not the reality.

The recommendation made by the task force applies to the entire population, but the decision about whether to get a PSA test is personal. The American Cancer Society recommends that men worried about prostate cancer — or with a family history of it — discuss the pros and cons with their doctor. You can still get a PSA test if you want one. If the results go up year after year, or suddenly spike, then you and your doctor have to grapple with what to do next — and those aren’t easy decisions.

A survey of 125 primary-care physicians that was released last week found that three-quarters of them are inclined to keep giving the test — because patients expect it and want it.

Also, 66 percent of the 125 physicians surveyed by researchers at Johns Hopkins University said they will keep giving the test because, in the words of the poll, “it takes more time to explain why I’m not screening than to just continue screening.” And more than half agreed with this statement: “By not ordering a PSA, it puts me at risk for malpractice.”

So, despite the best evidence we have, widespread PSA testing will likely continue.

The practice feeds a story we all want to tell ourselves: I did something. I was cured.

Well, maybe.