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The U.S. Preventive Services Task Force recommends doing away with prostate cancer blood testing as part of routine medical screening. The panel found that, while one in 1,000 men could be saved by the screening, many more will undergo unnecessary–and often dangerous–treatments as a result. We talk about the risks and benefits of prostate-specific antigen tests.
- Nortin Hadler Rheumatologist; author "Worried Sick: A Prescription for Health in an Overtreated America" (UNC Press) and Professor of Medicine, UNC School of Medicine
- Michael LeFevre Co-vice Chair, U.S. Preventive Services Task Force; Future of Family Medicine professor and associate chair of the Department of Family and Community Medicine, University of Missouri School of Medicine
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Later in the broadcast, cowboys and gals in a saloon, Shakespeare's "The Taming of the Shrew" as you may like it. But, first, having your blood tested for prostate-specific antigens, better known as a PSA screening, has long been a sort of medical rite of passage for men of a certain age.
MR. KOJO NNAMDIThose days may be coming to an end. On Monday, an influential federal advisory panel recommended men stop having their PSA levels checked, saying the tests do more harm than good. The recommendation is not without controversy. One group of urologists released a statement saying they were appalled by the decision, which they deem irresponsible and inexplicable. Joining us to have a conversation about this is Michael LeFevre.
MR. KOJO NNAMDIHe is a co-vice chair of the U.S. Preventive Services Task Force. He's also future of family medicine professor and associate chair of the Department of Family and Community Medicine at the University of Missouri School of Medicine. He joins us by phone from Columbia, Mo. Dr. LeFevre, thank you for joining us.
DR. MICHAEL LEFEVREThank you for the invitation.
NNAMDIAlso joining us by phone is Nortin Hadler. He is a professor of microbiology and immunology at the University of North Carolina, Chapel Hill. He's also author of several books, including "Worried Sick: A Prescription for Health in an Overtreated America" and "Rethinking Aging: Growing Old and Living Well in an Overtreated Society." Dr. Hadler, thank you for joining us.
DR. NORTIN HADLERIt's a pleasure, Kojo.
NNAMDIAnd, Dr. LeFevre, I'll start with you. What does a PSA test show doctors? And why did the group that you are a member of recommend that this testing be dropped?
LEFEVREWell, I think that the bottom line is that, after a thorough review of the best science that tells us what we can expect with PSA screening, the task force concluded that many men will be harmed by prostate cancer screening and few, if any, will benefit. The science shows us that, at most, one man in 1,000 screened will avoid a prostate cancer death, and that particular estimate comes from a European study. In the best and largest study done in the United States, we actually found no benefit at all.
LEFEVREIn contrast, many men will be harmed by the tests and the treatments that result from the screening. And most of the men who are treated would have lived just as long and just as well without the diagnosis and treatment of their cancer. But in a few numbers on that, of those same 1,000 men screened, two to three will have a serious complication of treatment, such as a blood clot or heart attack or stroke, even in a very few cases death, and up to 40 will have impotence, urinary incontinence or both.
LEFEVREAbout 30 to 40 men out of those 1,000 will also have less serious but bothersome harms from the prostate biopsy, such as pain, fever, bleeding, infection or need for hospitalization. And so, again, the bottom line is that the assessment of the task force is that the science demonstrates a very, very small benefit and significant harms. And we don't think that that benefit outweighs the harms, so we recommend against the routine use of this test in practice today.
NNAMDIWhat exactly does the PSA test show, however?
LEFEVREWell, the PSA test -- PSA stands for prostate-specific antigen, and it is a chemical that is specific to the prostate. It is certainly not specific to prostate cancer. That's one of the problems, actually. And if we biopsy men who have a particular pattern of PSA values or achieve a particular level of PSA, we can find cancer. We know that. Of course, we also know that if we biopsy everybody's -- every man's prostate in this age range, we can find cancer about 25 percent of the time.
LEFEVRESo it's not a surprise that we'll find cancer in response to biopsies that result from a PSA. The problem is that a very high percentage of those prostate cancers do not need to be treated, and the men will do just as well without treatment. But we don't know which ones, so, as a result, most men end up getting treated and suffer the potential complications related to that treatment, and most of those unnecessarily.
NNAMDIDr. Hadler, there are medical professionals who -- and others who say that comparing the risks of death from prostate cancer to dangerous possible side effects from treatment is really like comparing apples and oranges. What do you say?
HADLERKojo, let me offer a couple of comments that relate to perspective for the audience.
HADLERI've been on the faculty of the University of North Carolina and a professor of medicine for 40 years. At the start of my career on the faculty, a conversation like this was impossible. Most of what we did was based on eminence and best guess and best opinion and the power of the individual who claimed to have the best insight. And now, we're in the 21st century, and we're having a conversation about efficacy.
HADLERAnd that's so important, and the country needs to understand how important this transition is. For the first time in the history of my profession, a patient can go before a doctor and say, how certain are you that something will advantage me, and, if you're pretty certain it will, how much will I be advantaged? That's a totally different conversation than was possible 40 years ago.
HADLEREverybody ought to feel empowered to do that. For the first time, the patient is the captain of the ship. The doctor is the navigator. I expect my patients to ask me what's the basis for any advice I give, and that's the first issue we have to face, that this is a new conversation, one that ought to be commonplace today and certainly will be commonplace in the future. And we're talking about screening.
HADLERAnd screening is a grail for medicine. We would love to be able to find some important disease before our patients knew about it and do something that made it highly unlikely that they would ever know that they had that disease. There's nothing wrong with screening. But the country has to understand that screening is different from diagnostics.
HADLERScreening is a test done because we said you should have it on April 1 of every year. If you have a question and you come to the doctor with your question -- for example, if a woman says, there's something strange going on with my breast, and the doctor says, I think we need a mammogram, that's not a screening test. That's not a screening mammography. That is a diagnostic test.
HADLERAnd the results are far more likely to be informative as a diagnostic test in response to a complaint than they ever would be as a screening test. Screening is very, very hard to do well. And, finally, we've been able to ask about some of the screening tests that we have been doing for the past 25, 30 years, how likely are they to benefit me, the patient, for me to have this done with some periodicity in the hopes that something good will happen.
HADLERAnd there are screening tests that seemed to work pretty well, like the pap smear for cervical cancer, although we're learning how to fine tune that, too, where we don't need it, where we do need it, how often we need it. And the screening test for PSA made so much sense. And, finally, we've done the science. And it says, yeah, it will be really wonderful if it worked, but it actually doesn't do what you think it's doing.
HADLERDr. LeFevre mentioned that he assumes that 25 percent of aging men have prostate cancer. The way I look at that data is that if you're 70, you ought to assume you have prostate cancer. In fact, if you're 65, you ought to assume that you have prostate cancer. And the question you're asking of the screening test is not do I have prostate cancer but do I have prostate cancer that I will die with or prostate cancer that I will die from.
HADLERThat's the question we're asking. And if we screen with that question in mind, it turns out that we're incredibly ineffective in finding the prostate cancer that you want me to find, the one that you will die from, not the one that you will die with. And so the U.S. Preventive Services Task Force and Dr. LeFevre and his colleagues have looked at the science. And there is an informative science, and it says, wait a minute, even though we wish we could find the cancer that you will die from, we do that very poorly, probably not at all.
HADLERAnd in the exercise of trying to find it, we do a fair amount of harm for the possible finding. For example, Dr. LeFevre is saying that if I screen 1,000 men for nine years by one protocol or another, I may save one death from prostate cancer. Lots of things will happen to those 1,000 men. Other things will happen to them even that relate to their prostate. But we can only talk about maybe saving one out of 1,000.
HADLERI would submit to everybody that when you hear that, this is not a lottery. This is not somebody wins. This is, how likely am I to do well, die of a ripe old age at the same time if I don't buy the lottery ticket, if I don't have the screening? And the answer is probably essentially as well. So what we're looking at is the notion of screening, the notion of screening for an important disease and the science that says we've got to go back to the drawing board. The PSA is not doing what we want it to do at all. We need a better test.
NNAMDIWe're going to take a short break. When we come back, we'll continue this conversation with Dr. Nortin Hadler. He's a professor of microbiology and immunology at the University of North Carolina, Chapel Hill. Dr. Michael LeFevre, he is co-vice chair of the U.S. Preventive Services Task Force. He's also a future of family medicine professor and associate chair at the Department of Family and Community Medicine at the University of Missouri School of Medicine.
NNAMDIWe're talking about prostate screening and taking your calls at 800-433-8850. Have you or a loved one had a PSA test? What happened as a result? Would you or have you taken a watchful waiting approach to an elevated PSA level? 800-433-8850. I'm Kojo Nnamdi.
NNAMDIWelcome back to our conversation on PSA screening with Michael LeFevre, co-vice chair of the U.S. Preventive Services Task Force and future of family medicine professor and associate chair of the Department of Family and Community Medicine at the University of Missouri School of Medicine, and Nortin Hadler, professor of microbiology and immunology at the University of North Carolina, Chapel Hill.
NNAMDIWe got an email from John, who said, "Based on a high PSA test, at age 49, I was diagnosed with prostate cancer and had a prostatectomy at age 50. This cancer would have killed me long before something else, given my age at onset. As it is, I'm now 61 and have had non-detect PSAs for the last 11 years. Shouldn't there be annual testing for men between 40 and 60, and then if tests set still at four or below 60, stop the annual testing at this point?" What say you, Michael LeFevre?
LEFEVREWell, first of all, let me say that I understand that change is hard. And we've been told for decades to fear cancer and that the only hope is early detection and treatment. And physicians and patients alike, I think, have a hard time accepting that not all cancers need to be detected or treated and that there are harms associated with screening, not just benefits. This is particularly difficult to accept when there are so many personal stories that seem to contradict the science. Literally, many thousands of...
NNAMDIIf I may -- If I may be allowed to interrupt, I think we do have one such personal story. And I'll ask you after we talk with Linda, Michael LeFevre, to resume the thought you were expressing. But here is Linda in Silver Spring, Md. Linda, you're on the air. Go ahead, please.
LINDAHi. Yes. I'm just calling to say that my uncle died about 15 years ago, before all this information was known, as a result of having had an elevated PSA and then a biopsy and then surgery for prostate cancer. He was 75, and he -- within 24 hours after the surgery, he had a severe heart attack and languished for about a month, had heart surgery and then was very ill, a horrible death, for about a month and then ultimately died.
LINDAAnd also a close friend who had a biopsy, a much younger man, and then got a very bad infection and was in the hospital and very seriously ill from the biopsy itself from an elevated PSA -- from having had to deal with an elevated PSA.
NNAMDIOK. Linda, thank you very much for your call. Michael LeFevre, are those some of the risks about which you speak?
LEFEVREYes. We've just heard from two different people, two different stories, and the stories are what we can expect to hear following prostate cancer screening. You know, as I was about to say, literally, thousands of physicians and over a million men have had the experience of having a PSA screen, getting a cancer diagnosis and then treated. And they attribute their survival to that screen. But the science tells us that a very high percentage of those men would've done just as well without the PSA screen.
LEFEVREAnd the science also tells us that there are complications associated with following that pathway. And Linda just described for us some of those complications. I think that a man is entitled to know what the science tells us about the possibility of benefit and what the risks of opening that door and walking through are and make a personal decision about whether they think that the benefit outweighs the harms and not just say, this is your only hope. Go to the lab. I think that's the bottom line.
NNAMDIWell, Nortin Hadler, take a listen with us to George Washington Medical Faculty Associates urologist Dr. Compton Benjamin who is in favor of continued PSA screening.
DR. COMPTON BENJAMINThere are high risk populations that, I think, should be screened, all people with family history of prostate cancer and African-Americans. African-Americans especially have a higher rate of prostate cancer than do non- African-Americans, and, also, when found, have more advanced disease or more aggressive looking disease.
DR. COMPTON BENJAMINAnd I think that that population needs to have better surveillance in terms of screening to determine when prostate cancer is found so that we can then have the appropriate treatment. I personally will continue to have my PSA tested because I think that people who are at high risk of having high-grade disease, or high risk of having prostate cancer in general, should be screened.
NNAMDIYou, on the other hand, Dr. Nortin Hadler, have personally declined PSA tests for years. Why, and how would you respond to Dr. Benjamin?
HADLERWell, Dr. Benjamin makes important points, and he may be right. It may be that there are subsets that we can identify in the population for whom the screening will be higher yield than it has been in these large studies that have been done. And he's also perfectly correct in pointing out that African-Americans were not well-represented in the particularly large data sets. But my response would be, before we assume that there is a subset for whom more benefit will derive from a screening program, we ought to study it.
HADLERSuch studies need to be underway. What you do before the data is in, it has a lot to do with your sense of risk taking and your doctor's sense of risk taking. This gets back to we have elements of uncertainty, and Dr. Benjamin may be correct. I would love to see the data. Hopefully, it'll be generated quickly. What I will tell you, though, is that the kind of data we're looking at is looking for very small benefits, very small effects.
HADLERIf we're looking at -- the best we best we can talk about is to screen 1,000 men for close to a decade and maybe save one life, I would submit that that's very hard, very difficult effect to reliably demonstrate in the human population. It would be a difficult effect to reliably demonstrate if you had 1,000 inbred mice. We're not as good at finding these tiny little things as -- tiny little benefits and harms as everybody thinks we are.
HADLERIn fact, we're probably better at finding tiny little harms than we are in finding tiny benefits. That's why one year, if you give your family butter, you're a criminal, and, the next year, if you give them margarine, you're a criminal. There -- we are looking at small effects that are very difficult to demonstrate in out-bred populations, which fortunately very -- we are all different people. We all have different approaches to our doctors and to our health care and to life and to other important variables.
HADLERAnd it's hard to find these tiny effects. So I would submit to Dr. Benjamin that maybe we ought to do the study in the subset that he thinks is a greater risk, but not look for a trivial benefit. Look for an important benefit. If we can find an important benefit, by all means, we ought to be screening that subset. And if we can't find an important benefit, then we shouldn't be screening that subset. We're more likely to do harm than advantage to the patient.
NNAMDIMichael LeFevre, what do you say?
LEFEVREI think that -- first of all, let me just say that the task force is very sensitive to the racial and ethnic health disparities that exist in the United States. And we're keenly aware that African-American men have a higher risk of being diagnosed with and dying from prostate cancer. But we don't know why. I think my bottom line with that is that physicians should not use race as a reason to screen without an honest discussion about what is known and what is not known about the effects of screening black men.
LEFEVREAnd I certainly support research that would answer that question for us. Right now, we don't have an answer to the question. And I think that African-American men should be aware that we don't have evidence, that the balance of benefits and harms is different. If they still want to be screened, I'm supportive.
NNAMDIWell, for listeners wondering what this means for them, what it means for them when they or their loved ones visit their doctor, allow me to be more specific and ask Frank in Alexandria, Va. to tell us his situation. Frank, you're on the air. Go ahead, please.
FRANKOh, thank you. Your show is so timely for me. I'm scheduled for surgery on June 5 to have a radical prostatectomy. I was diagnosed last August and felt very uncomfortable about going with surgery at that time. My PSA was a six, and that was the indicator. And, since then, they ran the bone scans and all that and X-rays, and it didn't appear that it had spread. And they encouraged me to have some type of treatment.
FRANKMy Gleason score is -- well, I had three -- so on both sides of my prostate, I had three cores out of 12 that tested positive, two on one side, one on the other. And my Gleason score, the high is one seven and two sixes. So I was curious if your study would apply to me as well.
NNAMDIObviously, neither of our doctors have seen or examined Frank. But, Michael LeFevre, he asks if, in the context of the study on which you sat on the task force, he's, I guess, making a good decision.
LEFEVREWell, I think that he's in the very situation that we find ourselves in when we do PSA screening, which is we find cancers. We can't say with certainty that a cancer is going to lay there dormant and not harm you or whether that's a cancer that is going to be a threat to your health. And in that context, many men feel pressured by family, friends, their own sense of values, as well as their physicians, to undergo treatments which may or may not be beneficial.
LEFEVREI'm not going to pretend to offer specific advice other than to say, in general, if there is any lingering anxiety about having surgery, I would certainly find another doctor to get a second a opinion from. Some of the details that you provided suggest that some urologists might think that a more conservative approach is appropriate. But, again, I'm not hearing necessarily all of the details. But, I think, whenever a man is faced with the decision about whether to treat or not, getting more than one opinion is of value.
NNAMDIWell, we can get another opinion from Dr. Nortin Hadler. What say you?
HADLERWe're right up against the major issue in screening. You mentioned that I'm well known for not letting people screen my PSA. For that matter, my cholesterol -- in fact, there was a big article about that in The Washington Post a decade ago. And the reason is that I may be professor of medicine, but I'm also a man. And if I get a PSA that's up, I'm going to lose sleep. It's -- it is called the labeling effect. I will think of myself differently.
HADLERSo before I even get the PSA, I need to talk downstream with whoever is offering the screening test. What if? What if it's up? What if it's not up? What if it's up and -- I repeat it and it's not up? How do I conceptualize all this? Because we ought to be able to explain the downside and the downstream events before you get your PSA. And then you can say, wait a minute, maybe I don't want to be screened because I don't want to go that route.
HADLERBecause the data says that going that route doesn't increase my likelihood of dying without -- from something other than prostate cancer. In fact, it doesn't have anything to do with the date of my death. I will die, and I don't care if I die with prostate cancer. And since you can't tell me you can avoid that, death from prostate cancer with the PSA, I'd rather not know to start with.
NNAMDIFrank, thank you very much for your call. Good luck to you.
FRANKOK. Thank you.
NNAMDIHere is Ralph in Potomac, Md. Ralph, you're on the air. Go ahead, please.
RALPHExcuse me. Thank you. Several years ago, I wrote an article for Medical Crossfire and looked at the various studies. And without taking a lot of time on the program here, there was a Walter Reed study that showed that prior to the PSA tests and so forth that the prostate cancer was -- the cause of death was 37.5 percent in a 10-year period compared with 15.4 percent after the PSA test. So that's one thing I'd like to mention.
RALPHThe other is that I think that many doctors really rush patients into biopsies with the consequences thereof, without really considering the complete spectrum of PSA density, free PSA -- I mean, PSA density, free PSA percentage, PSA velocity, doubling time and so forth, and there are other consequences thereto. And then, yes, there are other consequences or the debilitating effects of incontinence possibility and certainly impotence as a result of doing the prostate cancer.
RALPHAnd for the years that we've been counseling patients, and especially focusing on the sexuality and intimacy, there are ways around it. And for many men that have the high Gleason scores, above the seven, and the PSAs make sense to consider, whether they are appropriate for the watchful waiting as pioneered by Hopkins or by the -- or going through a radical prostatectomy.
NNAMDIHere is Michael LeFevre. Michael LeFevre.
LEFEVREYes. There were a couple of issues raised in there that are worth addressing. Let me just say, first of all, again, one of the problems that we have with PSA screening is that there's no approach to the PSA, whether you look at density or velocity or level or anything else, that can assure a man that he doesn't have a dangerous cancer or that can assure a man that we're not going to harm him unnecessarily. We may be able to generally classify people at being somewhat higher risk or lower risk. But men are oftentimes looking for assurance, and we usually can't provide that.
LEFEVREI would like to say just a quick word about the decline in mortality rates from prostate cancer. We saw a gradual increase, over about two decades, in the rate of death from prostate cancer in the United States which peaked in about 1992. And then it reversed, and we saw that trend come back down again. We don't know why it was rising, and we don't know why it turned around, though we can say with certainty that the reversal in the trend was not due to PSA screening.
LEFEVREIt was just beginning to take hold in the early '90s and probably as early as the mid-'90s, so it would be the earliest we could say that it had penetrated enough to have potential population effects. The studies show us that it takes at least seven years before we're going to see any possible change in mortality rates.
LEFEVREAnd so we can say it with pretty high confidence that none of the decline that occurred in the '90s was related to screening. I do think that it probably represents improvements in treatment and probably improvements in health care overall. And so judging the decline in prostate cancer mortality to be due to screening is a pretty tenuous assumption.
NNAMDIAnd, finally, Nortin Hadler, are there other routine medical tests that either already fall in to the same category or that, in your opinion, should?
HADLERWell, you know, you never -- again, we're talking screening tests and not diagnostic tests. You never ever do a screening test ever unless the test is accurate, the disease is important, and we can do something about it. If it fails on any of those criteria, then you need to sit there with your physician and say, what's the advantage to me of doing that screening test? And we have a lot of -- a number of commonly offered screening tests that failed. For example, screening well people for their cholesterol level, that's now an accurate test.
HADLERIt is not a disease. It's a test for a risk factor. And if its primary prevention, you're otherwise well. Taking a statin has not saved lives, and you need to sit there with your doctor and say, why am I swallowing that pill? We're all very aware of the debates that are similar to this debate for mammography, and that debate is a very informative debate. Women need to understand what this -- what the limitations of screening mammography are. Remember, I started out saying this is not a diagnostic discussion. It's a screening discussion.
HADLERAnd now we're about to walk into the world of screening for minimal cognitive impairment as a so-called pre-Alzheimer's state, and the FDA has recently approved a very expensive new screening test for minimal cognitive impairment as a pre-Alzheimer's event. And what I would say to your audience is, if any doctor offers anyone that test, that patient needs to look the doctor in the face and say, how certain are you that this will benefit me?
HADLERHow many people have a positive test who don't go on to Alzheimer's? How many people who are demented have a negative test? Tell me what the test actually offers me. And if you're still comfortable having the test, so be it. I can tell you that there'll be many people who ask that question, who will step back from the test and say, wait a minute. That's not offering me enough information for me to lose sleep over a false positive.
NNAMDIAnd I'm afraid we're just about out of time. Dr. Hadler, thank you so much for joining us.
HADLERIt's a pleasure.
NNAMDINortin Hadler is a professor of microbiology and immunology at the University of North Carolina Chapel Hill. He's also the author of several books including "Worried Sick: A Prescription for Health in an Overtreated America" and "Rethinking Aging: Growing Old and Living Well in an Overtreated Society." Dr. LeFevre, thank you for joining us.
LEFEVREThanks for inviting me. Appreciate being here.
NNAMDIMichael LeFevre is a co-vice chair for the U.S. Preventive Services Task Force. He's also a Future of Family Medicine professor and associate chair of the Department of Family and Community Medicine at the University of Missouri School of Medicine. We'll be taking a short break. When we come back, cowboys and gals in a saloon, Shakespeare's "The Taming of the Shrew," well, as you may like it. I'm Kojo Nnamdi.
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