I recently had an awkward conversation with my doctor. I was getting a routine physical, and he recommended that I get a PSA test for prostate cancer. I’m 63.
I told him the PSA test harms more men than it helps. He acknowledged that PSA tests produce false positives, but he insisted that follow-up tests and biopsies will determine whether you really have a life-threatening cancer. He knew someone whose life had just been saved by the test.
When I still declined to get tested, he looked as though he felt sorry for me. He should feel sorry for the millions of men who have gotten unnecessary biopsies, surgery and radiation as a result of taking the PSA test.
PSA stands for prostate-specific antigen, an enzyme produced by the prostate gland, which is located below the male bladder. The test, which was developed in the 1980s, looks for elevated PSA levels, which can indicate cancerous cells in the prostate gland.
The problem is that inflammation and other problems unrelated to cancer can also elevate PSA levels. And when the PSA test correctly detects cancer, it is often so slow-growing that it would never have caused death or even impairment of health. Detection of these non-deadly cancers is called overdiagnosis.
In 2012, the U.S. Preventive Services Task Force, a federally funded panel of experts, recommended against the PSA test, saying the cons outweighed the pros. The decision was based primarily on data from two large studies, one done in the U.S., which found that screening did not reduce mortality, and the other in Europe, which showed a modest reduction.
This spring the task force upgraded its assessment slightly, based on new data from the European study. The task force still does not recommend the PSA test, but it says physicians should discuss its “potential benefits and harms” with men 55-69 years old. The task force found no benefit for younger or older men.
The New York Times broke down the statistics behind the new assessment as follows: If 1,000 men ages 55 to 69 get tested regularly for 10 to 15 years, 240 men will receive a positive PSA result, which is usually followed by a biopsy. 100 will receive a positive biopsy result, 80 will receive surgery and/or radiation, and 60 will suffer side effects from this treatment, including incontinence and impotence. One to two deaths from prostate cancer will be prevented.
Just to be clear: you are 240-120 times more likely to misdiagnosed as a result of a positive PSA test and 80-40 times more likely to get unnecessary surgery or radiation than you are to have your life saved. These data are based on this draft document of the task force.
The task force analysis is more favorable to the PSA test than a 2013 study by Cochrane Group, an international collaboration that provides impartial assessments of medical procedures. The group carried out a meta-analysis of five major studies of the PSA test, including the U.S. and European trials examined by the U.S. task force. The combined data showed “no significant reduction in prostate cancer-specific and overall mortality.” Digital rectal exams were also found to be ineffective.
The report added: “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity… Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence.”
The American Academy of Family Physicians recommends against routine PSA screening, but many physicians, like my doctor, continue to promote them. To understand why, read the important new book An American Sickness by Elisabeth Rosenthal, which reveals how greed has corrupted health care. Rosenthal, who got her M.D. before becoming a medical journalist, notes that the PSA test has created a “huge industry for testing and surgery.”
As an example, she points to urologist David Samadi, who runs a program for robotic prostate surgery at a New York City hospital and is a medical correspondent for FOX News. In 2014 Samadi created “The Samadi Challenge,” which urges women to pester “the men in their lives” to get PSA tests starting in their 40s. Samadi “makes around $3 million a year,” Rosenthal reports.
The discoverer of the prostate-specific antigen, pathologist Richard J. Ablin, called the PSA test “a profit-driven public health disaster” in The New York Times in 2010. He estimated that 30 million American men are tested every year at a cost of at least $3 billion.
The test may benefit men with an especially high risk of prostate cancer, such as those whose relatives have died of the disease, Albin acknowledged. But he argued that the medical community must “stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”
PSA tests have done to men what mammograms have done to women. How can physicians ethically promote tests that cause so much harm? Isn’t that a violation of the Hippocratic oath? And how can consumers allow themselves to be bullied and frightened into getting such flawed tests?
Now excuse me, I need to find a new doctor.
See follow-up post: Why We Overrate Life-saving Power of Cancer Tests