By Kristen Kridel, Special to the Tribune
November 9, 2011
For most of the last decade, Ronald Vari watched helplessly as his PSA level steadily rose, all too aware that the pattern could be a sign of prostate cancer. Yet initial biopsies didn't detect the disease.
Confused and frustrated, the Chicago resident began to question the worth of the PSA, a routine blood test that recently has come under fire from a federal health care panel.
"I was on their side before (doctors) found the cancer," said Vari, 60, whose PSA tests ultimately led to his diagnosis. He now believes the screening saved his life.
"You have to keep doing it," he said. "If you gave up, who knows what the results would be?"
Some local experts and doctors also believe the government-appointed U.S. Preventive Services Task Force was wrong to suggest that men without symptoms forgo the PSA test.
The task force found that early detection of prostate cancer often leads to unneeded surgeries and radiation treatment, which can cause life-altering side effects even though they don't always extend the life of the patient.
Some task force critics agree that the PSA, or prostate-specific antigen, test is imperfect but believe it's the best option available to detect one of the most common forms of cancer, which claims about 32,000 people each year in the U.S.
And experts say many of the task force's concerns about treatment can be minimized by experienced physicians using up-to-date guidelines and techniques.
"In general, I think it's a bad idea to encourage all young, healthy men to stop" getting tested, said Dr. Scott Eggener, urologic oncologist at the University of Chicago Medical Center. "PSA screening definitely saves lives."
In its draft recommendation released in October, however, the task force asserts that the harms of PSA screening outweigh its benefits.
Though the test detects many cases of asymptomatic prostate cancer, the majority of men whose cancer is found through a PSA have slow-growing tumors that will not affect their life spans or health, the task force said.
The panel pointed to evidence indicating that 95 percent of men with prostate cancer detected through a PSA test did not die of the cancer within 12 years, even those who didn't get "definitive treatment."
"The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit," the task force's draft statement said. "For men aged 50 to 69 years, the evidence is convincing that the reduction in prostate cancer mortality 10 years after screening is small to none." Prostate cancer is rare before age 50.
But local experts point to other data that they say show that PSA screening, which began in the early 1990s, reduces prostate cancer deaths.
From 1992 to 2005, the age-adjusted prostate cancer death rate in the U.S. dropped almost 40 percent, according to the federal Centers for Disease Control and Prevention.
Before the PSA test, many men weren't diagnosed with prostate cancer until it had already spread, "and they died from it," said Dr. William Catalona, Northwestern University urology professor and director of the prostate cancer program at the Robert H. Lurie Comprehensive Cancer Center. "And it's a really terrible death."
Eggener said improvements in treatment cannot alone account for the drop-off in the death rate.
Vari, whose prostate was removed last year, said that for years the only indicator of his cancer was an elevated PSA. Without the test, Vari said, doctors wouldn't have discovered his aggressive tumor in time.
"The biggest concern I had was ... not knowing if there was cancer — years of anguish and not knowing," he said. "Finding it was the biggest relief that there is. ... I was very fortunate."
Catalona, a prostate cancer screening pioneer, also asserts that the task force didn't properly interpret the research it cited. The panel combined data from studies of varying quality, thus diluting results from the more rigorous studies that showed a more positive outcome from PSA testing, he said.
Eggener said he's the first to admit that PSA testing is imperfect. Some men with high PSA levels are cancer-free; other patients with lower levels get aggressive cancers. But those scenarios are the minority, he said.
PSA screening is "the best test we have," Eggener said. "Generally speaking, every study that's been done (on a population) shows that your PSA is correlated with risk of having cancer, risk of being diagnosed with an aggressive cancer and your risk of dying from cancer."
Eggener agreed that men whose life expectancy is less than a decade are less likely to benefit from PSA tests and more likely to be harmed by prostate cancer treatment. But he believes that healthy men who are likely to live at least 10 more years should undergo PSA testing.
Catalona recommends annual PSA testing for men starting in the 40s, up to age 75.
Despite the task force recommendation, Dr. Joseph Goldstein, a family practitioner in Des Plaines and Palatine, said he has continued to recommend the PSA test for men older than 50 because finding problems earlier gives patients more options. So far, none has decided against it.
"I think we've been saving a lot of lives with it," he said. "By not doing the test at all, we might be denying somebody something."
But besides the screening, it's the ensuing "considerable over-treatment" of prostate tumors that also concerns the task force. Many men diagnosed with prostate cancer endure serious side effects from treatment — incontinence and erectile dysfunction are the big two — when their cancers are too slow-growing to cause harm in their lifetimes, the panel said.
Nearly 90 percent of men with PSA-detected prostate cancer receive treatment, which can include surgery or radiation, and at least 20 to 30 percent of men who undergo such treatment experience "adverse effects," the task force said.
Eggener said the task force recommendation does raise many concerns that doctors should discuss with prostate cancer patients before they undergo treatment. Besides just a PSA number, doctors can consider other factors, like the feel of the prostate and biopsy results, to determine if a cancer is aggressive enough to warrant treatment.
If a cancer is determined to be a low-risk form, patients can opt for active surveillance, which usually involves checkups and PSA tests every six months and biopsies every one to two years.
"Low-risk prostate cancer has an incredibly low risk of ever causing problems in the future," Eggener said. "If at any point it seems to grow, it's still very curable."
Chicagoan Robert Martin, 74, chose the active surveillance route when he was diagnosed with prostate cancer last year. Knowing his father also developed prostate cancer and lived almost to 100, Martin said he would rather not risk the potential side effects of treatment.
"It's such a nebulous thing, this prostate cancer. There are different ways of attacking it," he said. "I don't want to rush into something."
Catalona said he wouldn't recommend active surveillance for men with a long life expectancy. Men often miss the opportunity to be cured, he said, because either the cancer spreads or a sampling error made it appear low-risk when it really was aggressive.
Aggressive prostate cancers are misdiagnosed as low-risk 30 percent of the time, he said. And Catalona stresses that treatment doesn't mean patients will end up incontinent or impotent. Having performed about 5,600 nerve-sparing radical prostatectomies, Catalona said, he has thousands of patients who have no such side effects.
Terry Cray, 54, and his twin brother, Tom, both had their prostates removed on the same day in 2003. Within weeks, any issues he had with incontinence were gone, Terry Cray said. After three months, erectile function was normal.
The worst part of the entire experience was getting the call that he had cancer, Cray said.
"Basically for cancer, it was a walk in the park," said Cray, of Vernon Hills. "We were pretty lucky."
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