By Paul VanDevelder
Special to the Los Angeles Times
1:51 PM EST, December 19, 2011
When my family doctor called five years ago with the news that my PSA levels had spiked, I hung up the phone and did what all of us do. I panicked. I thought, "So this is how I'm going to die."
Then came the delayed second reaction: This can't be right! I'm a teetotaling, nonsmoking, very fit middle-aged baby boomer, a husband and a father of a 13-year-old daughter. This just wasn't in the Tarot cards.
Fortunately, I have five or six very close doctor friends, so I called one of them right away. He sent me to the bathroom.
"Look in the mirror and tell me — are you on fire?" he asked.
"No, I'm not on fire."
"Good. Now get a grip and relax," he ordered. "A rising PSA is not a death sentence. Chances are slim to none it's even cancer."
I've spent most of my adult life working as a journalist and an author, so I took my friend's advice. Having gathered my wits, I set about turning my fear into the same skepticism and curiosity that have stood me well on thousands of stories. Investigate! Get informed! Become my own expert!
Since that time, I've amassed a head full of results, facts, medical opinions and statistics on screenings for prostate cancer.
Five different studies, involving tens of thousands of men, showed that 7 out of 8 men with elevated PSAs will be cancer-free. Other studies found that having sex can raise your PSA (prostate specific antigen) levels, as can prostatitis, urinary tract infections, vigorous exercise and ibuprofen. This means that 88% of the men with elevated PSAs have what are known as "false positives."
Of those who do test positive for cancer, the vast majority have non-life-threatening cancers.
It was clear from my research that disagreement was growing among medical experts over the value of PSA screening. Richard J. Ablin, emeritus professor at the University of Arizona and a pioneering PSA researcher, came to call the use of his work "a profit-driven public health disaster." In his view (and those of many others), tens of thousands of unnecessary surgical procedures are being performed each year because of PSA tests, at a cost of tens of billions of dollars.
In October, the U.S. Preventive Services Task Force (an independent board that advises the government on preventive medicine) made big news when it recommended that doctors stop using the PSA blood test to screen healthy men for prostate cancer.
The report unleashed a firestorm of negative reaction from urologists (prostate specialists), just as the task force had expected. The panel had already navigated a similar storm in 2009 after advising doctors to stop using mammograms to screen normal-risk women in their 40s for breast cancer.
Dr. Michael L. LeFever, co-vice chairman of the task force, delayed the PSA-test announcement for two years to review the data, explaining when the recommendations were made public, "We absolutely have to have the science right."
These new studies and recommendations present men with a stubborn paradox. Despite testimonials from numerous men and women who believe that PSA tests and mammograms saved their lives (truth with a small t), the overwhelming evidence points to very different conclusions for most (truth with a big T).
Upon releasing his own study on the effectiveness of mammograms in screening for breast cancer, Dartmouth Medical School researcher Dr. H. Gilbert Welch described the conundrum this way: "The presumption often is that anyone who has had cancer detected has survived because of the test, but that's not true. In fact, and I hate to say this, in screen- detected breast and prostate cancer, survivors are more likely to have been overdiagnosed than actually helped by the test."
The medical community too faces very prickly questions about primum non nocere — "First, do no harm" — the vow every doctor makes when he or she takes the Hippocratic Oath. The verdict now in on prostate screenings and mammogram tells us that thousands of doctors in the United States are probably doing their patients more harm than good. This is the elephant in the national medicine chest.
None of this is to say that these cancers are not killers. Unfortunately, studies also show that early detection makes very little difference in mortality rates among people afflicted with the most aggressive kinds. In the context of cancer, Einstein was wrong. God does roll dice.
On the flip side, the vast majority of men who contract prostate cancer will die with the cancer, not of it, because the cancers grow too slowly to hurt them.
Since the PSA test was approved by the Food and Drug Administration as a screening tool, more than a million prostatectomies have been performed. Of those, more than 300,000 men have been rendered impotent and/or incontinent by what may have been unnecessary surgery. Though some lives will have been saved as a result of PSA screening, this must be viewed in the context of the latest and largest study, of 150,000 men, which found that surgical proceedures would have to be performed on 49 men with little or no benefit in order to extend the life of one man. Furthermore, 1% of men who undergo surgery die on the table from complications.
I have two close friends who were diagnosed with prostate cancer more than 10 years ago. Both decided against surgery, opting instead to live with it. Both tell me they are very happy with their decisions.
Another friend who was diagnosed with prostate cancer just last year chose to have the prostatectomy. "Going into the surgery, I felt very good about my decision," he says. "Today, eight months later, I realize I panicked. If I had it to do over, I wouldn't choose the surgery. Maybe later, but not now."
Over the last five years, my PSA has bounced up and down. (My father's PSA has followed a similar pattern over a 24-year period.)
At my last checkup, my PSA was still in the moderate range, and my free PSA level (above 20%) suggests that I have a 10% chance of having cancer. Given those stats and a normal digital rectal exam and no family history, I'm following the American Cancer Society's guidelines — retest in a year.
If I test positive for cancer in the coming years, the type of cancer (slow-growing or aggressive) will play a role in what I decide to do, but I suspect I'll pass on the surgery until I look in the mirror and see a fire.
I put it this way to my urologist: "If your doctor told you that an asymptomatic, non-life-threatening tumor was growing on the instep of your left foot, would you cut your foot off?"
"You're a tough case," he said with a laugh. "No, I wouldn't cut my foot off! Go ahead and get dressed — and go enjoy your life."
Think I'll do just that.
Journalist, author and screenwriter Paul VanDevelder has written for Audubon Magazine and the Los Angeles Times. His book "Savages and Scoundrels: The Untold Story of America's Road to Empire" won the 2011 Oregon Book Award.
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