Should I Be Tested

Many studies of men who have undergone regular exams for prostate cancer, including digital rectal exams and PSA testing, suggest that such precautions save lives. Comparison of 173 men in Minnesota who died of prostate cancer with 346 matched controls reported that only 61 percent of the men who died had had a digital rectal exam in the previous nine years, compared to 81 percent of the men in the control group. The authors of the study concluded that a ''screening [exam] may have prevented 50 percent to 70 percent of deaths . . . due to prostate cancer.'' A study in Washington State of 171 men who died of prostate cancer and 342 matched controls similarly found that ''men who have been screened with DRE [digital

''They say I have a special skill in diagnosing prostate cancer.''

rectal exam] and/or PSA are at lower risk of mortality from prostate cancer than men who have not been screened.''1

The most convincing data, however, come from a study in Austria in which PSA testing was made available without charge to men in one Austrian state but not in others. Within five years, more than two thirds of men aged 45 to 75 in the state with free PSA testing had been tested one or more times. Two years after the study began, the death rate from prostate cancer began falling in that state significantly more than in the other states; the researchers claimed that this trend was ''the first evidence . . . that the policy of making PSA testing universally available and at no cost may have led to a reduction in death from prostate cancer in that population.''2

In contrast to these studies, a highly publicized 2006 study of 501 men who died from prostate cancer in New England reported that screening by PSA or digital rectal exam did not save lives. The authors suggested that physicians should not use the reduction of mortality as a justification for endorsing ''routine testing of asymptomatic men.'' An accompanying editorial, however, noted that 78 percent of male primary-care physicians and 95 percent of male urologists aged 50 and over do have their PSA tested. Two large studies of PSA testing are currently in progress. One, the PLCO Cancer Screening Trial, has registered 74,000 men in the United States; the other, the European Randomized Study of Screening for Prostate Cancer,

PSA Tests as a Godsend

All the debates notwithstanding, PSA tests are a godsend. . . . You should know your PSA number just as you know your cholesterol count____When I sit in meetings at work and look at groups of men who are my contemporaries, I want to shout at them, ''Do you guys know what your PSA is?''

—Andy Grove, ''Taking on Prostate Cancer,'' Fortune, May 13, 1996

has registered 172,000 men at five European sites.3 Results of the two studies are expected in 2006 and 2008, respectively. In the meantime, men must decide whether to heed the existing evidence or await definitive results.

Because of such discrepant results, widespread PSA testing continues to be controversial. Some authorities argue that since three quarters of PSAs between 4 and 10 turn out not to be cancer, such testing leads to unnecessary biopsies, expense, and anxiety for the men involved. They point out that PSA testing is not sensitive enough, since it misses 15 percent of men who have significant cancer even though they have PSAs of less than 4. They argue that it has not yet been conclusively proven that PSA testing actually saves lives. Finally, they note that autopsy studies of men dying from other causes have found small foci of prostate cancer in almost all older men, so technically almost all men have some cancer. Opponents of PSA testing received further support in 2004 when Thomas Stamey and his colleagues at Stanford University publicly claimed that ''the PSA era is probably over for prostate cancer in the United States.''4

Predictably, other researchers immediately responded that ''the PSA era is not over for prostate cancer.''5 They pointed to data suggesting that PSA screening has been the main reason for the decrease in advanced tumors. For example, between 1983 and 1985, only 75 percent of men diagnosed with prostate cancer were alive five years

Kojak's Mistake

Telly Savalas, the bald actor who played the television detective "Kojak," had come in with a PSA of 10, he recalled. ''Dr. Skinner scheduled the biopsy, but Savalas had a Christmas special and cancelled it. Then he needed a vacation. I called to tell him how important it was, but he never came back. Four years later he was gone.''

—David Horowitz, The End of Time later. Between 1995 and 2000, 99 percent of men so diagnosed were alive five years later.

Because of the continuing disagreement about the value of widespread PSA testing, an independent panel of experts was assembled under the Agency for Healthcare Research and Quality. They could not agree either and concluded that ''the jury is still out on the value of routine screening'' and that ''patients should talk with their clinicians to make individualized decisions.''6

The cycle is complete: men have for years been told that they must make the decision regarding what treatment to pursue if they get prostate cancer. Now, men are also being told that they must make the decision whether even to be tested to determine whether they have prostate cancer. At first glance, it all sounds very democratic, but the truth is that few men have sufficient information to make informed decisions. Is it any wonder that many ignore the whole business and avoid testing altogether, baffled by the plethora of facts and the indecision of experts?

To me it seems self-evident that PSA testing, combined with a digital rectal exam, is not only worthwhile but one of the few things a man can do to diagnose cancer early and possibly save his life. Much of the confusion comes from thinking of PSA testing as either negative (3.9 or lower) or positive (4.0 or higher). We saw in Chapter 2 that PSA is a continuum and becomes valuable as a diagnostic tool

when measured on a regular basis so that the rate of change (PSA velocity) can be calculated. The argument that almost all older men have microscopic foci of cancer cells in their prostate glands does not negate the value of checking PSA; the testing is an attempt to identify men who have a microscopic focus that, for whatever reason, is growing into a full-blown cancer.

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