Let me get this straight. Twenty-five years ago, Urologists popularized a blood test for the early detection of a silent but very common and deadly cancer. With this tool in hand, called the PSA test, hundreds of millions of men have been screened worldwide since, changing the face of this cancer on the planet as we know it. What used to be a near fatal disease on presentation, prostate cancer is now curable in most men. And trust me, it’s not because more men decided to jump up and offer to have routine rectal exams over the last several decades!
What do We Tell Them?
Despite this, here we are in the middle of Prostate Cancer Awareness Month and this little-old-blood-test-that-could is mired in controversy. Hard to believe, kind of like the Bill Cosby story. Essentially, medicine is reeling after the Feds decided that the PSA test gets a grade of “D” as a screening test for prostate cancer and recommended against its routine use. A “D” grade??? Urology is a pretty competitive medical subspecialty, and I would vouchsafe to say that very few of us have ever gotten a D on anything they’ve done.
So urologists, who deal with prostate cancer every day, swear by the PSA test but the Feds, who look at cost of care to populations, don’t recommend using to screen for prostate cancer. Well, what’s a guy to do?
Kick Some Doors Down
I think the answer is to become “aware” of what’s going on. Most medical societies have belief statements on what they think about PSA screening. Here are the recommendations of some of the country’s most august societies:
American Urological Association. Routine PSA screening should be considered in men ages 55-70 but not before and not after. Screening should be considered every 2 years instead of annually.
American Cancer Society. Men age 50 years or older with a 10 year life expectancy should consider PSA screening.
Memorial Sloan Kettering Cancer Center. Men ages 45-70 should have a baseline PSA and decisions regarding further screening made based on life expectancy (> 10 years) and initial PSA level.
What all of us in medicine agree upon is that men at higher risk of prostate cancer should get screened earlier than men with average risk. What makes a man at higher risk of prostate cancer? Basically, age >50 years, African-American ethnicity and a family history of a brother or father with prostate cancer are the major risk factors.
In my view, using a screening test to find silent cancers makes great sense. Look at pancreatic cancer, which has no reliable screening test: even today, many cases are detected way past the stage of curability. While it’s true that prostate cancer generally grows much more slowly than other cancers, and may be something that men die with, and not of, we should not withhold the diagnosis by simply not screening for it. It’s like putting your head in the sand. Armed with excellent information that is now available about the likely course of their cancers, surely men so empowered will have an opinion regarding whether they should be treated or followed. In the words of Ralph Waldo Emerson: “Trust men and they will be true to you; treat them greatly, and they will show themselves great.” Now, come join me in a Urology Care Foundation tweet chat on Wednesday, September 30th at noon PDT to talk more about it. Join in using the hashtag #KYStatsChat.