Tuesday, September 20, 2011

Crowdsourcing my PSA test choice

I had my annual physical yesterday, and my doctor and I were discussing whether it is worthwhile to have a PSA test.  (My previous test results, as late as last year, were very low.)  As I understand things, the test is not proven to be determinative of anything.  So, even if the value goes up dramatically, it is not necessarily a sign of cancer.  It might, for example, be a noncancerous condition like BPH.  The test can also produce false negatives, i.e., an indication that all is well when cancer is in fact present.

As noted here, by the man who invented the test:

[Richard J.] Ablin has been frustrated by the widespread use of the test. Each year, he notes, some 30 million men undergo PSA testing, at a cost of $30 Billion.  Yet “the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. “

He acknowledges that “Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer. But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”

Gary Schwitzer quotes from the American Cancer Society website:

"The American Cancer Society recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information."

So, there we have it.  Should I cause scarce health care dollars to be spent on a test that will not give me useful information?  Or, to put it another way, why go through the potential stress of a higher number if it is not necessarily indicative of a problem?  Or should I cause these dollars to be spent so, if the number remains low, I have a false sense of security?

Your thoughts?


Cheryl Clark said...

From Facebook:

Ask Otis Brawley, MD, who during an interview with me in the early part of the last decade, pooh poohed the psa, to see if he has changed his mind. He is now the chief medical officer of the American Cancer Society. He pooh poohed it, even though he acknowledged that as an African American, he has a higher risk of prostate cancer.

Unknown said...

My father had the PSA test with elevated levels (borderline, really) and had a needle biopsy to find out that he has the non-aggressive type of prostate cancer. The needle biopsy was not without its complications and he landed in the ER with a variety of infections (and subsequent allergies to antibiotics). He is not receiving treatment at this time, and he is proceeding with his life normally.

I think it's not so much about the test itself, it's about what you would do with the information. If you were to have a borderline high result would you take action, or not?

The Medical Contrarian said...

Seems like a no-brainer but somehow the whole idea of cancer screening, first popularized by Dr. Bloodgood of JHH in 1923, holds sway over both the medical profession and lay public, despite the likelihood the tools (such as the PSA) are next to worthless. There is something extremely powerful about the illusion of believing in our ability to predict the future. This is even more powerful when veiled in the trappings of technology.

Laura said...

stress in itself can be as dangerous as cancer

@jordangrumet said...

From Twitter:

I tell my family to skip it.

Patricia said...

From Facebook:

What about waiting a year or two? Since you are in good health, have no symptoms, and don't seem to be at risk, you might decide to have the test after your next physical or the one after.

jdfitz said...

I vote skip myself - 61 year old male Internist. I'd rather take the very small risk of cancer than contribute to the overmarketed, highly profitable, industry-driven prostate screening scam. I see too many men who think they are cancer-survivors -I think that what they survived was the treatment for elevated psa. Seventy percent of older men will have cancer cells in their prostates. Take a pass. JD Fitz

Elon said...

Why don't you get the traditional test instead?

Paul Levy said...

It is not either-or, Elon.

BTW, @jordangrumet, above, is a primary care doctor.

Mitzi said...

I'm a graduate student in biochemistry who did a lot of research about this between my husband's biopsy and diagnosis (losing several pounds from the stress of reading the literature in the process). According to an article just published in the Annals of Oncology, it depends on your level. With a level below 3 ng/ml, screening in men over 50 can have intervals of greater than 3 years and be fine. I've read another study that suggested that a single test around age 60 is just as predictive of future problems as the current annual screening. From our traumatic experience (and my microscopist-suspicion of the biopsy result images), I would PASS.

Anonymous said...

Interesting use of crowd sourcing :) I would say to skip it if you expect the results won't tell you anything useful either way.