Outside Panel Backs Prostate Test Advisory
McCaughey: American men should disregard this dangerous change of guidance. The U.S. Preventative Services Task Force has no oncologists or urologists among its members. It is unqualified to make a recommendation. The American Urological Association immediately denounced the Task Force guideline.
The United States has the highest survival rates for men diagnosed with prostate cancer, over 99%. It is not a death sentence in America. But in Europe nearly one out of every four men diagnosed with prostate cancer dies from it. The reason is the United States aggressively screens and treats prostate cancer. In Europe, doctors are told to pursue “watchful waiting,” a strategy that delays treatment until cure is no longer possible.
American men don’t want to be Europeanized, and die early from prostate cancer.
By Gardiner Harris
In the wake of a government panel’s advice last week that healthy men should no longer be routinely screened for prostate cancer, an independent team of experts sought to explain, in an assessment of the scientific evidence in a prominent medical journal, why a simple blood test generally results in more harm than good.
The review, published online Friday in the Annals of Internal Medicine, provides the scientific justification for the United States Preventive Services Task Force’s recommendation that men should no longer have an annual P.S.A. — prostate-specific antigen — test. The task force’s recommendation, which was supposed to come out after the review’s publication, leaked out on Thursday.
Members of the task force, who foresaw that their recommendation would be greeted with skepticism and outright opposition from some doctor groups, hired experts at Oregon Health Science University to conduct a thorough review of the evidence.
The Oregon team identified five clinical trials that sought to assess whether men who got routine P.S.A. tests were less likely to die of prostate cancer than those who did not get the testing. Three of the trials were weak, said Dr. Roger Chou, an associate professor of medicine at the university. “They were older studies with significant flaws, although none of them found any benefit to screening,” he said.
The results of the two stronger trials were published in March 2009 in The New England Journal of Medicine. One of them was conducted in the United States over seven years and followed 76,693 men ages 55 to 74, half of whom were given annual P.S.A. tests. The other trial, conducted in Europe, involved 182,000 men ages 50 to 74 from seven European countries who were given P.S.A. tests every four years.
Like all such large studies, both had their flaws. For instance, about half the men in the control group of the American trial who were not supposed to be screened regularly got screened anyway by their own doctors at some point in the study.
The American study found no benefit to prostate cancer screening. Those who got screened were far more likely to have prostate cancer detected, got more treatment for it and also were slightly more likely to die from prostate cancer than those in the control group, though the difference was statistically insignificant. In the European study, men ages 55 to 69 who were screened saw a 20 percent reduction in mortality from prostate cancer, but because the total number of deaths in the study was so small the benefits of screening were also small. Across all ages studied, screening provided no benefit in the European study.
The problem with screening for prostate cancer, Dr. Chou said, is that the vast majority of men who have cancer in their prostates will never be bothered by it. But once they know they have cancerous cells in their prostates, many men insist on aggressive treatment — including having their prostates removed or irradiated. Such treatments lead many to suffer impotence and incontinence for the rest of their lives.
“The idea that knowing you have a cancer isn’t always a good thing is a very difficult concept for many people,” he said.
Dr. Virginia Moyer, the chairwoman of the task force, said that since widespread P.S.A. testing does not save lives but leads many men to undertake treatments that result in significant harm, the task force’s recommendation against P.S.A. testing “theoretically is a no-brainer. It’s obvious.”
“The problem is that this runs up against most people’s understanding of cancer, which is that when you have cancer, it will progress and you will die,” she said. “If you see cancer as always deadly, it seems impossible that P.S.A. testing would be harmful. But that’s not the way prostate cancer behaves.”
Many urologists have decried not only the task force’s recommendation against P.S.A. testing but the scientific rationale underlying it. Dr. Carl Olsson, chief medical officer of Integrated Medical Professionals, the largest urology practice in the United States, said the task force chose to focus on the wrong studies. He pointed out that prostate cancer deaths in the United States had declined steadily since widespread P.S.A. testing began.
“I think the concept of having us give up on the identification of people who have prostate cancer as well as on their treatment is a backward step to say the least,” he said.
But Dr. Gerald L. Andriole, chief of urology at Washington University School of Medicine and the lead author of the 2009 screening study performed in the United States, said there was a compromise between complete rejection and widespread embrace of P.S.A. testing. He suggested regular screening only for those at high risk for the disease — including black men and those with a family history of prostate cancer.
“Rather than throw P.S.A. away, we should make the plausible adjustment that only certain men should be screened,” Dr. Andriole said. “I guess you would say I’m trying to split the difference.”