To test or not to test. That is the question that has sparked one of the most heated debates in medicine today. What is this? Prostate cancer and the PSA test. If you are a patient, it is like watching a heavyweight boxing match, and we are only half way through the bout. In one corner we have the US Preventive Services Task Force (USPSTF) who recommends against screening for prostate cancer with PSA, giving it a grade of D. The American College of Physicians recommends screening in men 50-69 years old only after discussing with their doctor. The American Urological Association recommends men 55-69 years old discuss with their doctor the value and risks of screening. The American Cancer Society recommends beginning at age 50 for those of average risk and only after shared decision making with their doctor. Confusing? Extremely! What is a patient to do?
Patients want to know. How much so? Just take a look at the recent three part Twitter chat on prostate cancer. It was consistently one of the top trending issues on Twitter.
Enter Dr. David Samadi, Chairman of Urology at Lenox Hill Hospital in New York City, who has boldly issued the #SamadiChallenge. Cleverly, he enlists the best healthcare advocates known; women. He challenges women to:
- Learn the prostate cancer risk factors.
- Improve the lifestyles of the men in their lives.
- Encourage men to get screened annually.
- In case of a positive diagnosis, urge men to seek treatment.
Why is it important? Some background on prostate cancer will help illustrate the magnitude of the problem. Prostate cancer is the number one cancer in men. The American Cancer Society expects more than 221,000 new cases this year with 27,500 deaths. The National Cancer Institute estimates a man’s lifetime risk of developing prostate cancer at 16%, statistics strikingly similar to breast cancer.
Samadi says, “Healthcare is at a fork. We can be our own doctor or depend on guidelines. However, guidelines are a moving target.” He points out that no urologist is on the USPSTF.
I know well the shortcomings of PSA. I see it regularly in biopsies done for an elevated PSA only to reveal inflammation and benign prostatic hyperplasia (BPH). Even more challenging is the discovery of small, low grade cancers that many consider incidental and never to cause harm.
As a pathologist I strive for appropriate test utilization. I realize the cost of testing to the system but I also know about the value of screening for disease. Look at the success with the pap smear, mammogram, breast self exam, lipid panels, blood pressure…the list goes on. No one would question those time honored practices.
Granted I am diagnosing more prostate cancer and I agree many are indolent and likely to never cause harm to the patient. However, this is a decision that your doctor makes with the patient based on age, family history, race, physical exam and other risk factors. This “shared decision making” is common ground that everyone agrees upon. That is the important point. We need to identify men at risk, and part of this involves knowing the PSA. Empowering men to be their own advocates is the goal.
To the critics countering by citing the harm of overdiagnosis and overtreatment, I point to what the mammogram and now tomosynthesis and MRI are doing to breast cancer detection. I am definitely diagnosing more because of the new modalities. And saving lives too. Much of the nearly 30% decrease in prostate cancer mortality observed during the 1990s was attributable to the PSA test according to one study.
Strictly adhering to guidelines creates risk. A disturbing all too frequent occurrence is the diagnosis of younger patients with high grade, aggressive cancers. I have seen this and the literature appears to support an increasing incidence in men under age 50. Following guidelines would miss them. I also diagnose cancer in patients with very minimal (and still within normal range) elevations of PSA. It is important to know a patient’s baseline, so that a subtle deviation can be pursued.
Once a cancer is found, there is still more debate. Treat or not? Some advocate treatment while in select patients, active surveillance is a valid option. Again, it is informed decision making that is crucial. This further illustrates the importance of being an informed patient and having these discussions with your doctor.
“As imaging tools such as prostate MRI improves and genetic testing advances, as well as other more sensitive tumor markers become part of our armamentarium, then perhaps one day the PSA test can become a secondary test. Until then, this is the only prostate cancer screening tool that we have with longest track record. While we understand that it is not the most specific test, I am anxiously waiting for more accurate tests in the future.”
Additionally, researchers, while focusing on mortality, did not factor in the pain and suffering of metastatic prostate cancer, something that was a not an uncommon presentation before widespread adoption of PSA screening. Taking away PSA would be akin to turning the clocks back to the 1980s. Evidence attesting to this comes from a large study that showed a 42% decrease in the incidence of metastatic disease due to screening.
New tests on the horizon include the PCA3, 4Kscore Test and Prostate Health Index tests. Time will tell whether these prove better.
I know well about the scientific method vs anecdotal evidence. What does the literature say? Excellent reviews can be found in these references. A large European study showed a decrease in mortality through screening, while an American study at the same time showed no benefit.
“Women fought successfully for mammograms. Men should do the same for PSA”, says Samadi. “70% of healthcare decisions are made by women. Women have historically been the better health advocate.” Samadi says enthusiastically, “to all women out there, please join me and accept the #SamadiChallenge and let’s save his life.”
Dr. Samadi offers a novel and controversial plan. Check out the #SamadiChallenge for yourself. Let’s hear from you and get the conversation started.
