AmyTuteurMD

AmyTuteurMD
Bio
Dr. Amy Tuteur is an obstetrician-gynecologist. She received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine. Dr. Tuteur is a former clinical instructor at Harvard Medical School.

Editor’s Pick
MARCH 18, 2009 6:05PM

Don't get screened for prostate cancer

Rate: 7 Flag

looking in shorts

What’s worse than being rendered impotent and incontinent by prostate cancer treatment? Being rendered impotent and incontinent by prostate cancer treatment that was unnecessary.

Two large, well-conducted studies revealed what doctors have suspected for quite some time. Screening for prostate cancer using the PSA (prostate specific antigen) blood test does not save lives. In fact, PSA screening for prostate cancer does more harm, including impotence and incontinence, than good. Due to their importance, both studies were released online today by the New England Journal of Medicine, in advance of their publication next week.

According to the study, Mortality Results from a Randomized Prostate-Cancer Screening Trial:

From 1993 through 2001, we randomly assigned 76,693men at 10 U.S. study centers to receive either annual screening(38,343 subjects) or usual care as the control (38,350 subjects).Men in the screening group were offered annual PSA testing for6 years and digital rectal examination for 4 years. The subjectsand health care providers received the results and decided onthe type of follow-up evaluation. Usual care sometimes includedscreening, as some organizations have recommended. The numbersof all cancers and deaths and causes of death were ascertained…

Results … After 7 yearsof follow-up, the incidence of prostate cancer per 10,000 person-yearswas 116 (2820 cancers) in the screening group and 95 (2322 cancers)in the control group. The incidence of death per 10,000 person-yearswas 2.0 (50 deaths) in the screening group and 1.7 (44 deaths)in the control group …

Conclusions After 7 to 10 years of follow-up, the rate of deathfrom prostate cancer was very low and did not differ significantlybetween the two study groups.

The two graphs below present the results of the study. The graph on the left represents cases of prostate cancer and demonstrates that PSA screening was much more effective in diagnosing prostate cancer than examination alone. The graph on the right represents deaths from prostate cancer. Despite a significant increase in diagnosis of prostate cancer in the PSA group, there was minimal if any reduction in deaths from prostate cancer.

prostate cancer graphs 

While deaths from prostate cancer were not decreased by PSA screening, serious side effects were dramatically increased.

Risks incurred from a screening process can result from thescreening itself or from downstream diagnostic or treatmentinterventions. In the screening group, the complications associatedwith screening were mild and infrequent… Medical complications from the diagnostic processoccurred in 68 of 10,000 diagnostic evaluations after positiveresults on screening. These complications were primarily infection,bleeding, clot formation, and urinary difficulties. Treatment-relatedcomplications, which are generally more serious, include infection,incontinence, impotence, and other disorders…

Why did the PSA screening test fail to save lives? The PSA screening test did diagnose more cancers than routine examination, so the test definitely works. The apparently paradoxical outcome is due to the nature of prostate cancer itself.

Most men will develop prostate cancer if they live long enough. However, most prostate cancers are very slow growing and usually do not kill the patient. A man with prostate cancer generally dies of some other cause long before the prostate cancer becomes life threatening. Therefore, the PSA test diagnoses many cases of prostate cancer that do not need to be treated as well as a few cases of prostate cancer that are very aggressive. Not only is there no benefit to diagnosing the slow growing prostate cancers, but there seems to be very little benefit to diagnosing the aggressive cancers early, since some do not respond to treatment even when administered in the early stages.

The second study,  Screening and Prostate-Cancer Mortality in a Randomized European Study, showed a very small decrease in deaths associated with PSA screening. That decrease came at a very high price:

To prevent one prostate-cancerdeath, 1410 men (or 1068 men who actually underwent screening)would have to be screened, and an additional 48 men would haveto be treated.

For every death prevented, 1068 men had unnecessary biopsies, and 48 men had unnecessary treatment. That’s a problem, and it is made far more serious by the life altering side effects of treatment, impotence and incontinence.

Taken together, both studies provide convincing evidence that PSA screening for prostate cancer should be stopped. Too many men are seriously harmed, and very few if any men derive any benefit. The take home message for patients: Don’t get PSA screening for prostate cancer.

blogspot visitor

Your tags:

TIP:

Enter the amount, and click "Tip" to submit!
Recipient's email address:
Personal message (optional):

Your email address:

Comments

Type your comment below:
I'll worry when I wake up and go to pee and it run downs my leg at a snails pace. Until such time...don't go near my anus. I already have enough that I'm dying from already (see tumor).
I read a study (or article) a few months ago that mentioned how strange it is that the U.S. still does PSA testing. Supposedly other developed countries consider it unnecessary and even annoying as it's an unnecessary cost, takes the lab's time, worries patients, etc.

I'm interested as to how true it is that we're one of the few countries still using the "out-dated" method.
"there seems to be very little benefit to diagnosing the aggressive cancers early, since SOME do not respond to treatment even when administered in the early stages."

You have to be freaking kidding me? I didn't see an alternative to PSA testing... only that even if you find it death at some point is a likely outcome. It doesn't seem to take into consideration the fact that finding it early and doing something about it may add years to your life. It doesn't acknowledge the value of your being one of the "SOME" that do respond to treatment.

As someone who has lived with prostate cancer... had a radical prostatectomy... experienced only a brief period of impotence... and is using PSA with both urinologists and oncologists to monitor my cancer... there is no way I can take this "study" seriously. Had I ignored the PSA test until I actually experienced symptoms ... I would likely be in that group reporting, "Oh well ... they were gonna die anyway."

If not PSA testing... then tell me what the alternative is?
What I took from a news item on the two studies recently published, the trouble may not be over-reliance on the PSA test, but over-aggressive treatment when the particular cancer is not so aggressive, thus making the adverse effects worse than they need to be.
Harp:

"It doesn't seem to take into consideration the fact that finding it early and doing something about it may add years to your life."

But it doesn't. That's the point.

Only a small minority of men who have prostate cancer have aggressive tumors and it is not clear that early detection makes ANY difference, even for them.

Look at the graph. There were more deaths in the group screened with PSA, not less.
What are the alternatives?
Confusing. So what are the 'normal' symptoms of prostate cancer? Maybe the normal symptoms are so glaringly obvious that very few men need the PSA test to know that there is something wrong when they pee-pee?
GeeBee:

"What I took from a news item on the two studies recently published, the trouble may not be over-reliance on the PSA test, but over-aggressive treatment when the particular cancer is not so aggressive, thus making the adverse effects worse than they need to be."

There is only aggressive treatment for prostate cancer. That's what everyone gets.
jimgalt:

"What are the alternatives?"

The alternative is to have a prostate exam (digital rectal exam) every year, and only get the PSA test if there is a lump or the prostate is enlarged.

The other alternative is to forgo any treatment if the prostate cancer is in its early stages.
Ignorance is not bliss. I would rather know if I had it and make my own decision.

My dad had it, got the operation, suffered side affects, and died a few years later from another cancer. So, he didn't need the surgery as it turned out.

My uncle (my dad's brother) had it, got the radioactive "seed" treatment and eventually died slowly and horribly from it. The treatment extended his life for a few years.

If I get it, I'll evaluate my options, but I damn well want to know that I have it.
It sure seems to me that "studies" like this that report what seems like "half-baked" findings to get their 15 minutes of fame are the kinds of things that I would expect our resident MD's to debunk. To go along with something that suggests risking your life because the knowing the cancer is their is not the immediate equivalent of curing it ... is terrible.

I want to talk to the people who are studying how many people have been saved or had their lives extended because they found evidence of prostate cancer that had not yet progressed to the exterior of the gland... or had not yet caused a discernible lump... and was only and solely detectible because of the PSA test.

That study won't be published will it?

It won't see print because there is nothing new about that information. That is what the industry has already been doing... and while we still cannot "cure" the disease... the practice is to use all possible means to detect and treat the findings according to the options available and the wishes of the patient.

I noticed also that the "study" mentioned nothing about the ages of the patients at diagnosis ... (it's far more agressive in younger patients) .... or even the nature of the options available... (nerve sparing surgery is the routine practice these days and impotence is not the default result.) This is a sensationalist report and the authors of this study should be ashamed of the potential harm they will do... even if their hearts are in the right place.

How could you possibly advise anything else?
I really hate that we can't go back and edit comments. (sigh)
Harp:

"I want to talk to the people who are studying how many people have been saved or had their lives extended because they found evidence of prostate cancer that had not yet progressed to the exterior of the gland... or had not yet caused a discernible lump... and was only and solely detectible because of the PSA test."

Both of these studies looked at exactly that, and they found that few if any men had their lives extended because of screening. That's the entire point.

Most doctors had already come to the same conclusion. Routine screening for prostate cancer does NOT save lives and it harms many men.
Thanks for this post. Thanks.
Good post. My dad had a positive test for prostate cancer recently (which turned out to be a false positive, by the way) and his doctor was very upfront with the information you've given here. He pointed out that given my dad's health condition and age, there was very little chance he would live long enough for the prostate to become an issue.

Note that he told my dad this AFTER being paid for the screening. ;)
"Routine screening for prostate cancer does NOT save lives and it harms many men."

I'm 52. My PSA is low. I do have an enlarged prostate.

I look at these studies and it confirms my 2 part game plan. At my current age I'll continue to have the PSA done. I have to have blood drawn anyway, what's one more test? A few dollars that I can afford.

Why get it done? I'm young enough that even slow growth cancer can be a problem before I get old. Aggressive growth means I'll have to hurry with the bucket list. If things change my doctor and I will talk about the options.

Now when I hit, I'm not sure say 70, I'll not worry about the test. At that point, aggressive or not, something is going to get me. Hopefully by that point I'll have done my life's work.

I do have to add that my FIL had a PSA that jumped through the roof. They did the needle biopsy on him. He got infected and he never got his health back. I think the test took years off his life. He was in his early 70's. I would have never had it done.
Ok, I'm probably safe then. My prostate only gets enlarged watching teenage lesbian cheerleader videos. No cause for concern.
This will be my last comment... because I am gong to bed. I also don't want to be mistaken for for someone jumping up and down on my desk. I believe that we can disagree without bursting a blood vessel.

To me this is confusing the detection device with the treatment. It's like saying you shouldn't have a fire alarm because the property may well burn anyway. I was in my 40s when I was diagnosed and it was an aggressive strain. I was then given my options and allowed to make an informed decision without undo pressure. The detection process (PSA monitoring followed by a biopsy) was entirely separate from the treatment decision... but early detection gave me better odds. I would have been given different options and different advice if I was considerably older.

One of my favorite sayings in business is, "Don't confuse selling with installing!" In this case, to say that the diagnostic is bad because the treatment is too harsh... suggests you need to go fix the treatment process.

Leave the diagnostic process alone.

Good night Doctor Amy.
This is a great example of a dangerous post.

Dr. Amy says that "most prostate cancers are very slow growing and usually do not kill the patient." This is not true unless we add some details.

It IS true that prostate cancer is slow growing in men age 75 and older. But it's not true in younger men. Men younger than 75 are more likely to develop an aggressive prostate cancer; this is why screening is essential.

Like any cancer, it's best for prostate cancer to be detected early, particularly in younger men. Like any cancer, prostate cancer can metastacize to other parts of the body, such as the lymph system and bones. Anyone who's ever had to deal with cancer knows just how bad that is.

Digital rectal screening is usually the first test used to screen men for prostate cancer. Your healthcare provider will insert a finger (digit) into the anus in order to manually check the prostate for abnormalities. Yes, it sounds unpleasant. Keep in mind that prostate manipulation can be pleasant; if you're really scared, go find a clinic with a hot female doc and do your best to enjoy it.

The next step is a prostate-specific antigen test (PSA). This is a simple blood test. Unfortunately, while it works for cancer detection, it will sometimes give what's called a false positive reading. False positive means that the test says you might have cancer when you don't.

My personal experience with PSA tests is that patients are not given certain instructions prior to having the test done. For instance, having a digital rectal exam within a few days of the test can result in an elevated reading (bad). Also, ejaculation has been proven to elevate PSA levels, so men should refrain from masturbating or sexual intercourse for a few days prior to this test.

The test isn't the problem here. The problem is the doctors and the patients and the patients' friends and family. Education is desperately needed.

Men 75 and over probably should opt for no treatment, unless they experience bothersome symptoms. It's highly likely that something other than the prostate cancer will be responsible for their eventual death.

My grandfather was diagnosed with prostate cancer at the age of 76. My grandmother absolutely freaked when she heard the "C" word. And of course she did. For that generation, the big "C"--cancer--was the worst thing possible. My grandpa had Parkinson's disease and some senile dementia; he wasn't able to make medical decisions for himself. My grandma spoke with everyone in the family; asked for my best medical opinion, which I gave; spoke with the damn doctors, who of course all recommended treatments in their fields of specialty; and decided on a course of treatment rather than leaving the damn cancer alone.

Because of the Parkinson's, my grandpa wasn't a candidate for surgery. An intensive course of radiation treatments left him incontinent; as a result, my grandmother could no longer care for him at home. He was placed in a nursing home, which he hated; suffered horrible rashes and urinary tract infections (UTI) due to substandard care, and finally died two Thanksgivings ago, hospitalized for a UTI turned sepsis. His urologist has, for some odd reason, prescribed a straight catheterization 4 times daily. Straight cathing is when the catheter (tube) is inserted into the bladder, then removed. Sterile technique is used to prevent infection. (After two more deaths at the same home for the same reason, we concluded that someone at the nursing home was neglecting their sterile technique.). Anyway, the ultimate cause of my grandfather's death was the cancer treatment, as he wouldn't have become incontinent and placed in the home had he not been treated for the prostate cancer.

About a year after my grandfather's death, my uncle was tested for prostate cancer for the first time. Following a digital rectal exam, he was tested for PSA, the result being 22 (a flurry of research by me for the family followed this result--22 is very, very bad). They did a biopsy and discovered that my uncle had multiple tumors in the prostate; the cancer was extremely aggressive. A bone scan relived us of our worry that the cancer might have already spread.

My uncle is currently undergoing intensive chemotherapy and radiation treatments. His PSA must drop to 6 before the surgeons can come in and remove the cancer. He spent a few days in a psychiatric unit after a minor breakdown; he's a single, 50 year old man who's never found the right woman. He's doing ok now. My uncle is certainly worried about the prospect of impotence, but he's more preoccupied with staying alive. Had he not been tested when he was, the cancer certainly would have taken his life.

After my uncle's diagnosis, I sounded the alarm in my family. All of our males MUST be tested ASAP, if they haven't been already. And they did, and will continue to be tested.

Regardless of the quoted study--and there's something a bit off about it; I'll mull it over and post if I come to any conclusions--I firmly believe in cancer screenings, particularly for those with risk factors, which I'll list:

If you have a father or brother with prostate cancer, GO GET TESTED.

If you have any family history of prostate cancer, GO GET TESTED.

If you are 50 and have never been tested, GO GET TESTED.

If you are a black man, GO GET TESTED.

If you are obese, GO GET TESTED.

If you consume a diet high in fat, GO GET TESTED.

If you have pain, or urinary difficulties (trouble peeing), GO GET TESTED.

Educate yourself! Be prepared for your test results. Don't have a PSA done within 3 days of a digital rectal exam. Don't have sex or masturbate within 3 days of your scheduled PSA, either.

Don't freak out if your test is positive. EDUCATE YOURSELF. Listen to the doctors, but also read about your options. Be prepared for the next step. Be aware of the decisions you will be asked to make. Be aware that every specialist will believe that a treatment in their field is best. Check the internet for current clinical studies. Find docs that you trust. Don't be afraid to get a second--or even third--opinion. Don't go alone; take someone along for support, even for testing. A positive result is a big smack in the face, and you'll need someone to lean on.

If you are 75 or older, or you are making decisions for a man 75 or older, please consider the option of no treatment. It's more pleasant for the patient if they have no annoying symptoms.

But not screening is ridiculous. Like I said, the problem is with the doctors--who ultimately control the treatments the patient may or may not have--and the patients. Exercise some control.

PSA screening saves lives. We cannot sacrifice those who lived due to PSA screening because of the faulty judgement and lack of self control on the part of the healthcare providers.
Oh, and one more thing...

Erections and bladder control don't do much for you if you're dead.
I really wish we could edit our comments! Sorry for the multiple posts.

It's just crap that "everyone" gets aggressive treatment. That's just not true. There's a lot of "wait and see" going on. There are stages of treatment. There are hormone treatments used to shrink the cancer. There's radiation seed therapy.

It IS true that no matter what you choose to do, you're going to be visiting the doctor a LOT.

Some other facts:

1 in 6 men will eventually develop prostate cancer. One out of every six is certainly a lot, but one out of six is not "most".

Nearly 100% of men diagnosed with prostate cancer in the local or regional stages were cured after 5 years. Seems like a good reason to get tested early, and often.

Usually, the patient will not experience any symptoms of prostate cancer in its early stages. This is why men need to be tested.

Dr. Amy, I usually respect your posts, but this one is truly dangerous. Please consider, for just a moment, how many men who read this post you--with a Harvard education--authored will not be tested as a result. Consider how many of those men may die, as a result.

I repeat: get yourselves tested(age 50). If you have risk factors, or don't know your family history, get tested early(age 40). Your docs don't make the final decision on treatments. You do. Get tested, do some research and make the best decision for you.
The study you linked concludes:

Conclusions: PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis.

20% reduction in deaths from prostate cancer is not insignificant.

I have to question whether or not you actually read through these studies.

It also mentioned that the men in the screening group were only screened every 4 years, and biopsies were done for a PSA level of 3 at some centers.

PSA is a valuable screening tool. The overreaction of healthcare providers to the PSA results should not be blamed on a test that saves lives.
Allie Griffith:

"My dad had a positive test for prostate cancer recently (which turned out to be a false positive, by the way) and his doctor was very upfront with the information you've given here. He pointed out that given my dad's health condition and age, there was very little chance he would live long enough for the prostate to become an issue."

I'm glad that he got appropriate counseling. Most doctors have suspected for quite some time that PSA screening does far more harm than good.
Harp:

"To me this is confusing the detection device with the treatment. It's like saying you shouldn't have a fire alarm because the property may well burn anyway."

You've given the wrong example.

Suppose that every time a fire alarm went off, the fire company came to your house, knocked in the windows, axed a hole in your roof and sprayed hundreds of gallons of water, ruining some of the furniture. Then suppose that most of the time that the fire alarm went off, there was either no fire, or a small fire contained in a trashcan. Would you want that fire alarm if the chances were 68 times higher that the alarm would lead to the destruction of your house rather than have any positive impact at all?
sickofstupid:

"It IS true that prostate cancer is slow growing in men age 75 and older. But it's not true in younger men."

Both studies were done on men ages 55-74.

You seem to be confused about the purpose of the study. It looked at routine screening for prostate cancer in men who did not have risk factors. People who have risk factors are in a totally different category.
These studies also demonstrate two other important principles. First, screening tests should not be instituted until there is scientific data that shows that they actually have benefit. Second, these studies demonstrate that preventive medicine is far less beneficial than lay people imagine it to be.

Many people reflexively assume that screening is always good. In order for screening to be beneficial, a number of things must be true:

1. The screening test must be able to pick up the disease at a stage where treatment will make a difference. In contrast, the PSA test does not diagnose prostate cancer at a stage where treatment affects the outcome.

2. The screening test should have a low false positive rate and a high false negative rate. In contrast, the PSA test has a high false positive rate.

3. If the screening test has a high false positive rate, the diagnostic test must have few if any risks. In contrast, biopsy of the prostate is a surgical procedure.

4. If the screening test leads to a treatment with a high rate of serious side effects, it must have a high rate of diagnosing cases that actually need treatment. In contrast, the PSA test diagnoses many more cases of people who don't need treatment than people who do, subjecting them to serious side effects for no benefit.

The Pap smear is another screening test that has a high false positive rate, but the Pap smear is tremendously successful. Why?

Pap smears diagnose pre-cancer, which can be cured with minimal treatment, and early stage cervical cancer, which require less aggressive treatment than later stage disease.

The diagnostic test used to follow up a false positive Pap smear is a minor in office procedure.

Almost everyone who is diagnosed with cervical cancer or precancer benefits dramatically from the treatment.

The important thing to keep in mind is that a screening test can provide no benefit. Only some screening tests are beneficial. Therefore, large scale testing should be done before routine screening is recommended.
One of the things I find ironic about this discussion is that it demonstrates that patients are never satisfied. Had I told you that a study showed that large scale screening for prostate cancer was beneficial, but it hadn't yet been implemented, people would have come out of the woodwork ranting that doctors hate preventive medicine because it deprives them of income. People would have fulminated that the only research that is published is research that enriches the medical profession.

Instead, I show you two excellent studies that demonstrate that doctors are making a fortune from screening tests that lead to very expensive diagnostic procedures and very expensive treatment, both of which provide no benefit, and both of which drive up healthcare costs dramatically. Now people are insisting that it can't possibly be true that doctors are making large amounts of money from unnecessary diagnostic procedures and unnecessary treatments.

Which is it?
Dr. Amy: (and I sincerely apologize if my address offends you; if so, please indicate your preference of address and I will comply)

I am not confused about the purpose of the study. I was commenting on your incorrect statements--which I consider dangerous and negligent--which I will respectfully repeat here:

You stated: "...most prostate cancers are very slow growing and usually do not kill the patient..."

This is a factually incorrect statement. Prostate cancer in men ages 75 and older are usually slow growing, so much in fact that patients will most likely die of other causes unrelated to the cancer. I would support recommending against PSA screening for men 75 and older who are symptom free.
Prostate cancers in younger men can be much more aggressive, and younger men have many more potential years to live. If you have sources that specifically say differently, I'd be happy to take a look at them.

You said: "Most men will develop prostate cancer if they live long enough."

This is another factually incorrect statement. One out of six men will develop prostate cancer in their lifetime. One out of six is not "most". Again, if you have sources that refute this, I'm happy to examine them.

You said: "While deaths from prostate cancer were not decreased by PSA screening, serious side effects were dramatically increased."

The study you linked stated that there was a 20% decrease in deaths from prostate cancer due to PSA screening. The study directly refutes your statement. As for the side effects, I'm not seeing much regarding that in the study. It did report that there were no deaths related to the biopsies. I will assume that you meant side effects from unnecessary treatments. My response to that again would be that healthcare providers are responsible for any unnecessary treatments, not the PSA screening. Doctors need to exercise some self control, and/or complete further training. They also need to ensure that their patients have accurate information prostate cancer treatments and side effects.

One problem I see with these studies is that around half of the men in the control groups (the groups that were not supposed to receive screening) were screened and treated for prostate cancer. So far, I have not seen any explanation of how this didn't affect the results of the study. (I'm still working my way through the tedium of multiple boring tables).

Another issue is that screening intervals were anywhere from 4 to 7 years. That's more than enough time for an aggressive cancer to kill someone.

Yet another issue is that the pathology was performed by local pathologists. Who's to say whether or not they are competant? And who is to say that the false-postives are due to the test rather than the human evaluating the results?

In the footnotes of one study, it clearly states that one study was initiated to determine whether a 25% reduction in prostate cancer mortality could be achieved. They achieved 20%. For me, that's close enough.

Another study's footnotes clearly indicate that more study is needed. "The ratio of benefits to risks that is achievable with more frequent screening or a lower PSA threshold than we used remains unknown. Further analyses are needed to determine the optimal screening interval in consideration of the PSA value at the first screening and of previously negative results on biopsy."

I don't think that it's appropriate for a physician to publicly recommend, without qualification, that men should not be screened for prostate cancer based on early results of studies that both report that further study is needed. In fact, I would go so far as to say that it's negligent.

PSA screening works. It's inexpensive; anywhere from $20-60, and you can purchase a home test kit for around $40. It does identify prostate cancer successfully. The test does have some problems, including false positives. But these can be dealt with through more specific research, more specific guidelines, further training for pathologists, and again, the reining-in of healthcare providers.

Saving 20% of lives that would have otherwise been lost is worth the cost.

Because it is important, I am going to repeat this.

If you are male and at least 40 years old, you should have PSA testing done if you have a family history of prostate cancer, particularly if a father or brother was diagnosed. I would recommend having the screening done yearly. If your insurance doesn't cover it, spring for the test out of pocket. Ask about the cost first, but it should run anywhere from $20-60. It is well worth the cost for the feeling of well-being and the reassurance for you and your family.

If you are male and at least 50 years old, you should be screened, especially if you have any of the risk factors below. Again, I would recommend being screened often.
--are black
--are obese
--consume a diet high in fat
--don't know your family medical history

Please get screened! And use some (un)common sense. You are in charge of your body and your medical treatments. You make the choices. Educate yourself so that you can make the best medical decisions about your conditions and treatments.
Thanks for the medical advice, Amy. Those are interesting studies.
Dr. Amy:

Nowhere in this post did you state that men with risk factors are in a different category. Nowhere did you say that men with risk factors should be tested. Nowhere did you give examples of risk factors so that men could figure out which category they are in.

You said: "Don’t get PSA screening for prostate cancer."

The studies you quoted both state that more research and study is needed. Neither study concluded that PSA testing should be stopped.
You said: "Taken together, both studies provide convincing evidence that PSA screening for prostate cancer should be stopped."

The studies said that PSA testing reduced 20% of prostate cancer related deaths.
You said: "...very few if any men derive any benefit."

You said: "screening tests should not be instituted until there is scientific data that shows that they actually have benefit."
The studies you linked demonstrate that PSA testing works and does benefit patients.

You said: "The screening test must be able to pick up the disease at a stage where treatment will make a difference. In contrast, the PSA test does not diagnose prostate cancer at a stage where treatment affects the outcome."
I would like to see some references for this statement. My research indicates that PSA testing can diagnose very early stages of cancer. As with any cancer, the best outcomes result from early detection. When prostate cancer is detected in the local or regional stages, the cure rate with treatment is almost 100% after 5 years.

2. The screening test should have a low false positive rate and a high false negative rate. In contrast, the PSA test has a high false positive rate.
Better to say you have cancer when you don't than to say that you don't have cancer when you do. Besides, the PSA test itself shouldn't be making the diagnosis. The treating doctor should use it as a diagnostic tool, in conjunction with the DRE, risk factors, other medical conditions, recent sexual activity and family medical history. The PSA doesn't say you have cancer; the doctors do. Therefore, the doctors have the high false-positive, not the PSA.

3. If the screening test has a high false positive rate, the diagnostic test must have few if any risks. In contrast, biopsy of the prostate is a surgical procedure.
Again, this is a decision made by the treating doctor. The PSA has nothing to do with a biopsy. The biopsy itself is a surgical procedure, but the complications are generally not major or permanent.

4. If the screening test leads to a treatment with a high rate of serious side effects, it must have a high rate of diagnosing cases that actually need treatment. In contrast, the PSA test diagnoses many more cases of people who don't need treatment than people who do, subjecting them to serious side effects for no benefit.
Again, this has nothing to do with the PSA. The treating doctor makes these decisions. Decisions should not be made based solely on the PSA, and if they are, it's no wonder that there's a problem with overdiagnosis. Faulty decision making, negligence, general laziness or malpractice should not be blamed on a diagnostic test.

I don't see anyone but you complaining about costs in this thread. Patients in general aren't asking for much. We want quality. We want to know our options. We want preventative care and treatment when appropriate. We want our docs to be focused on providing the best care rather than the most expensive. We do not want unnecessary procedures, but we do want our lives and our health.

With regard to the fire alarm anaology:

The PSA is like the fire alarm (good one, Harp). The fire company is the doctors. There's no good reason why the fire company can't simply investigate the cause of the fire alarm before aggressively and expensively fighting a fire that may not exist, just as there's no reason the doctors can't investigate an elevated PSA before instituting an aggressive course of medical treatment.

Maybe it's protocol to do a biopsy for a PSA of 4-7, as in the study. Perhaps the protocol needs to be revisited. At any rate, it's irresponsible to blame a test for the decisions doctors make, and it's incredibly iresponsible and dangerous to tell men not to be screened.
In my comment on screening tests above, the sentence "2. The screening test should have a low false positive rate and a high false negative rate. In contrast, the PSA test has a high false positive rate." should read:

2. The screening test should have a low false positive rate and a LOW false negative rate. In contrast, the PSA test has a high false positive rate.
sickofstupid:

"PSA screening works."

No, it doesn't work, no matter how much you'd like to think that it does. That's what these studies (and others) show. There appears to be no benefit in survival and many men unnecessarily harmed by treatment they didn't need.

Your comments are filled with factual inaccuracies, so many that I will not address them all, but here are some of the more egregious:

"One out of six men will develop prostate cancer in their lifetime. One out of six is not "most"."

One out of six men will be DIAGNOSED with prostate cancer in their lifetime. However, autopsy studies on men reveal that as many as 30% of men age 50 and older HAVE prostate cancer. The numbers are even higher for older men.

"The study you linked stated that there was a 20% decrease in deaths from prostate cancer due to PSA screening."

That is not particularly impressive when you consider that the absolute deaths rates were the same in both groups. The men in the PSA screening group were JUST AS LIKELY to die as the men in the control group. The only difference is that they were more likely to die of something other than prostate cancer.

You don't have to take my word for it. This is what the National Cancer Institute has to say:

"Benefits

The evidence is insufficient to determine whether screening for prostate cancer with prostate-specific antigen (PSA) or digital rectal exam (DRE) reduces mortality from prostate cancer. Screening tests are able to detect prostate cancer at an early stage, but it is not clear whether this earlier detection and consequent earlier treatment leads to any change in the natural history and outcome of the disease...

Harms

Based on solid evidence, screening with PSA and/or DRE detects some prostate cancers that would never have caused important clinical problems. Thus, screening leads to some degree of overtreatment. Based on solid evidence, current prostate cancer treatments, including radical prostatectomy and radiation therapy, result in permanent side effects in many men. The most common of these side effects are erectile dysfunction and urinary incontinence... "
Dr. Amy,

I genuinely respect your education and credentials. However, I cannot take your word over what the researchers themselves concluded in the studies that you linked. No one has to take my word for it either; all they have to do is read the first part of the study.

I'd also like to say that every word that I've posted here is supported by credible sources. I'm not talking out of my ass. If anyone wants the sources, just request and I'll post them.

One out of six men will be diagnosed with prostate cancer. That's not an inaccuracy. I have not located any information to support your claim that autopsies prove that 30% of men actually have (or had) prostate cancer, but for the sake of argument, let's say that it's true. 30% is a lot, but it's still not most. If you can push your number to 51%, I'll concede. Until then, I maintain that--as a licensed (presumably)physician-- it's irresponsible to publicly post this misinformation.

It doesn't really matter what those men died of. The point is that they didn't die from prostate cancer or treatments related to the prostate cancer. If they died from something else, it's irrelevant to this discussion. The PSA assisted with early cancer detection and prevented 20% of prostate cancer related deaths.

For every quote that you post, I can locate one saying the opposite from an equally reputable source. The evidence at this point is inconclusive, and I'm not arguing that.

What I'm saying is that the PSA test is not responsible for the decisions doctors make. It is intended to be used along with the DRE to be a diagnostic tool, not the definitive answer. A better method/protocol needs to be developed so that cancers that don't require treatment can be differentiated from those that do. That's the job of a human, not the job of a simple blood test.

I'm also saying that until all the reputable organizations and research physicians come out and say that men should not be screened, it's irresponsible to post that they shouldn't. It's particularly irresponsible to fail to mention that your post doesn't apply to men with risk factors (or symptoms, I presume).

I'd actually like to hear your position on that, since we've danced around it a few times. Do you support PSA screening for men with risk factors and symptoms?
If I were man, this is what I would take from what you're saying:

If I have no symptoms and no risk factors for prostate cancer, screening for prostate cancer won't extend my life. I'll die at about the same age regardless. But I get screened, I might be spending some of that precious time getting diagnostic procedures, surgery, possibly chemotherapy or radiation. I also risk losing bladder control and becoming impotent.

I think people might understand this entry better if the original post was edited to include some information about what groups of men do benefit from these tests.

I would be interested in reading your take on mammograms, since there has been some controversy regarding them in the last decade.

Any of us could go out and pay for a full body scan, and they'd probably find all sorts of weird things inside of us that aren't causing problems but potentially could. But would trying to cut them out, shrink them, or otherwise treat them help us in the long run when those options come with risks of their own?
Dr. Amy, you have failed to defend yourself against sickofstupid's many excellent points. Besides that....

This was an irresponsible headline, for the following reason:

as a lay person myself, I connect 'digital exam' as SCREENING.
I'm not an idiot. Certainly not one of the brightest bloggers here, but I'd guess that I'm just as smart as your 'average' OS member.So, when I saw your headline, I thought that you meant men shouldn't get any digital exam at all-I wasn't even thinking about the blood tests. Men tend to shy away from medical exams anyways-and you know how many people see your headlines each day. Even when we don't read your posts-we see the headlines.
How many men are going to see this headline today and subconsciously file it away in the back of their minds as 'I know I heard a famous Dr somewhere who said men don't have to get checked for prostate cancer.' ?

If you think I'm wrong about that, then I must say, for once, you are actually overestimating the intelligence of your readers. I'm going to go outside and watch the pigs fly through the air now....
Didn't I just read the same column last week, only replace prostrate cancer screening with ovarian cancer screening?
@Doc: Thanks for this article, it's always good to see a rational analysis based on real statistics and research. However I am a bit confused; the papers--and your own discussion--seems to refer to PSA screening, yet you make a blanket statement against screening. What about the DRE? Is that more or less reliable, or catching more aggressive cancers? Are you telling men to forgo both PSA screening and the DRE, and is this supported by research?

Secondly, while the papers do seem to conclusively show that outcomes are worse when patients have PSA tests--EVEN THOUGH the tests are actually working--doesn't that say something about the failure of the medical establishment? The tests work, they provide more information, yet patients have worse outcomes. Rather than saying "don't get tested, better not to know," shouldn't doctors be changing their practice and educating patients better?

For instance, with Mr. Sickofstupid's grandfather, if the doctors were actually urging open his family an aggressive course of radiation treatment for prostate cancer in a senile 76-year-old with Parkinsons, that sounds like malpractice to me (although with his pre-existing age and condition the damages are probably too low for an attorney to touch it on contingency). Throw in that he died of treatment complications and that looks like borderline wrongful death. What do you think?

Of course it is possible that the doctors fully explained all the options and risks and his wife freely and intelligently chose treatment to take a chance at an extended life.

But even if this is the case, don't doctors have an independent duty to evaluate for themselves what "first, do no harm" means, especially with an incompetent patient? Might not the doctors have determined that in a senile 76-year-old patient with Parkinsons, aggressive treatment was simply unethical and refused to do it?

But you are right that this is a no-win situation for doctors, since they would definitely be accused of paternalism for denying treatment demanded by family. But sometimes "paternalism" is called "professionalism." Octo-mom demanded six embryos from her physician and got them.
Here I go chiming in with a self-followup, but I would say in further support of your "don't get tested" advice is a factor you didn't mention which is the high financial cost of all this annual screening and followup. Even if doctors and patients acted rationally on test results, maybe all that medical expenditure would be better used elsewhere since it doesn't seem to be saving any lives.
I would be interested in reading your take on mammograms, since there has been some controversy regarding them in the last decade.

Yes, I'd also like to hear about this.
Ericacrochets:

"If I have no symptoms and no risk factors for prostate cancer, screening for prostate cancer won't extend my life. I'll die at about the same age regardless. But I get screened, I might be spending some of that precious time getting diagnostic procedures, surgery, possibly chemotherapy or radiation. I also risk losing bladder control and becoming impotent."

Exactly!
JenniferC:

"Didn't I just read the same column last week, only replace prostate cancer screening with ovarian cancer screening?"

Yes, it was very similar. In the case of ovarian cancer, the problem is that the screening test has a very high false positive rate and the diagnostic test is major abdominal surgery.

In the case of prostate cancer, the screening test has a very high false positive rate, but the more important finding is that it diagnoses many cancers that were not going to progress fast enough to be harmful.
nkennedy:

"yet you make a blanket statement against screening. What about the DRE?"

According to the information from the National Cancer Institute that I quoted in an earlier comment, the jury is still out on that as well. However, there is some reason to believe that it may be more beneficial because it can only detect cancers that are larger and therefore somewhat more likely to be aggressive than the cancers diagnosed by PSA screening.
But even if it was just one life saved...wasn't that life worth all of that unnecessary treatment?
@nkennedy:

It's actually Ms. Sickofstupid. ;)

My grandfather's doctors did explain the side effects. However, she was still urged to choose radiation by the radiation doc, and chemotherapy by the chemotherapy doc. She should have chosen to just leave it a lone, a fact I think she did recognize as the entire gathered at his bedside right before he died (no one was going to point it out, but she obviously felt some guilt). That her choice hastened his death and actually led to a poorer quality of life for him is something that she will have to live with.

And the jury really isn't out on DRE. DRE is supposed to be used in conjunction with the PSA, medical history, risk factors, etc., in order to determine whether to proceed with diagnostic tests, including biopsies. Dr. Amy neglected to include the part of the quotes she chose to share that say this. That's OK, because they are easy to find. Just Google "prostate cancer organizations" to see their recommendations for yourself. Also note that the docs running these studies concluded that PSA screening was useful in preventing 20% of prostate cancer related deaths, and that they are certainly not recommending that men stop having the PSA. In fact, no one other than Dr. Amy seems to be recommending that men not be screened. All reputable organizations are saying that more study is needed, including those who are running the studies Dr. Amy has based her opinion upon.

As Dr. Amy pointed out, some of the men died from other things rather than from prostate cancer. As I said, it doesn't really apply to the discussion here, but consider this: death from aggressive prostate cancer isn't pretty and it isn't fun. Nor is it easy. It's extremely painful, and more than likely will involve metastasizing to other parts of the body, like bones, and the lymph system, which allows the cancer to go pretty much wherever it wants to. I can think of many other manners of death that would be easier, less painful and that are over faster.

If you hav the patience to plow through or at least skim the studies linked, you'll notice that some participating clinics performed biopsies for PSA levels as low as 3, 4-7 being their overall average range. That's not OK; that's insane and completely unnecessary. A biopsy for a PSA of 10, yes. Anything less than that and I'd really question the decision to perform one.

I also did not see where in the study it states that these studies used men without risk factors, as Dr. Amy stated. That would be rather difficult, considering the fact that older men are much more likely to develop prostate cancer, and black men are almost twice as likely to develop prostate cancer than white men. I'm not refuting her statement, just saying that I didn't see it. I'll keep looking through the endless tables and post if I find it.

I'd like to add that when my uncle's initial PSA level came back, no one asked him if he'd engaged in any kind of sexual activity prior to the test. No one had bothered to tell him not to ejaculate for a few days prior to the PSA to avoid a falsely elevated level. These docs tend to jump to conclusions. While it's admirable that they want to treat aggressively and immediately, it's essential that they slow down and make sure that the patient actually needs the treatment they're trying to give him.

Yes, there's the risk of impotence, incontinence and other side effects from the treatments (not the tests), depending on treatments and if you actually choose to be treated. (There are virtually no side effects from the DRE and PSA. ) However, while older men are more likely to develop the slow-growing version, younger men are more likely to develop aggressive prostate cancer. Additionally, many, many men with prostate cancer had no symptoms. So with particular regard to the 40 year old men out there, those who opt out of screening are risking a sudden and nasty surprise. If the cancer is aggressive and is not discovered until you have symptoms, it's certainly not going to be any easier to treat, and could already be too late.

A better choice of course is to get tested. Know your PSA level, and keep an eye on it. Be involved. If your doc wants to do a biopsy, ask him why. Be informed. Know your treatment options, which include the option to do nothing, or hormone treatment to help shrink the tumor(s). And remember that ultimately, all treatment decisions are yours, not your doc's.

At this time, there are no reputable organizations that are recommending that men not be screened via the PSA and DRE. The doctors who are doing the clinical research studies are also not recommending that men stop getting tested. This, even if you choose to ignore everything else in this thread, should be the most telling.

I'm not trying to make anyone look bad. The thing is, when you're discussing a medical topic as a medical doctor, and your credentials are known to those you're speaking to, a certain level of credibility is assumed. Therefore, any medical professional that chooses to represent themselves as such needs to hold themselves to a higher standard when it comes to posting articles in public.

Posting your opinion is one thing, and should be labeled as such. Deliberately misrepresenting facts and study results in order to support your own opinion advising against the standard and accepted protocols is not OK.

Above all, please do your own fact-checking. Patient education is key for the best medical results.

I still have not heard from Dr. Amy regarding whether or not she supports testing for men with risk factors, as every reputable prostate cancer organization does.
@holly & Sickofstupid (sorry for the assumption): Speaking as someone who actually has a prostate, given the choice between a large chance of permanent incontinence and impotence for an unnecessary procedure and a small chance of horrible prostate cancer death, I'll take my chances.

Here's a thought: A double total mastectomy is just about 100% effective at preventing breast cancer. You never have to worry about it again. Want to sign up? If all women did this, millions of lives would certainly be saved, and "even if it was just one life saved...wasn't that life worth all of that unnecessary treatment?"

No, it's not. It would not be worth millions upon millions of other women being permanently disfigured. Only women with certain BRCA mutations who know that they will probably get early aggressive breast cancer do sometimes choose this type of radical prevention. And it's not worth it for dozens or hundreds of men to have to live life permanently impotent and incontinent to prevent one prostate cancer death.

The NIH, ACS, and all other major organizations have recommended against mass PSA screening since 1998. See http://www.cnn.com/2009/HEALTH/03/18/prostate.screening.debate.brawley/
As one who has had the needle biopsy 2x (2002 & 2008), both 100% negative, I can attest to the invasiveness of this procedure. The 2nd time, along with the usual side effects (bloody semen, bloody urine), there has been added a new wrinkle. While everyone has occasionally experienced an inability to completely void feces, this this is now the rule, rather than the exception. While trying to examine the prostrate with the ultrasound gadget, the doctor, unwittingly I am sure, managed to stretch the rectal muscles. It is only recently that I have regained a measure of freedom from the curse of going through rolls of TP in record time!
I'm a physician that recently had a PSA that lead to a biopsy. Fortunately, it was negative, but I understood the joke that PSA stands for "Patient's Severe Anxiety" only too well!
The studies show you're betting a 1 in 50 chance that your life will be saved (over 10 years) against a 49 in 50 chance that you will be treated unnecessarily. The treatment has a 50% chance of causing sexual problems and a 33% chance of incontinence.
So I won't be having another PSA.
@nkennedy:

Your link is incomplete. I don't know why that happens with long links in the comments; it's a right pain in the arse. Anyway, thought I'd let you know.

With a little effort, I did locate the article you were directing us to. However, I was unable to verify your claim (and the claim of the expert interviewed) that these organizations have recommended against mass screening since 1998. (I will keep looking though!) I did verify that these organizations warned that there was insufficient evidence to say whether or not mass screenings were beneficial (whether the benefit outweighs the risk). The organizations also recommend against screening in men age 75 and older.

I'm certainly not saying that we should be doing mass prostate screening. What I AM saying--and have been saying--is that a blog post, authored by a doctor who chooses to include her credentials in her username, entitled "Don't Get Screened For Prostate Cancer" is irresponsible because it is likely that at least some men who SHOULD be screened will view this post--or even just the title--and decide not to be screened because a doctor recommended against it.

Even the expert in the article you linked stated, "These studies are a significant lesson...They suggest that a man should be informed of the potential risks and potential benefits of screening and he should be encouraged to make a choice....I am also concerned that all the talk about these new studies will discourage men who should be treated...Please remember some men should be treated."

In my extensive research of prostate cancer (to enhance and refresh my professional knowledge and to assist in the explanation of facts and options to the laypersons in my family when we were dealing with two diagnoses of prostate cancer) I have yet to come across any reputable source that recommends against prostate cancer screening for men with risk factors or symptoms.

I think that healthcare providers need to do a better job of explaining the risks and benefits of screening to their patients.

I think that healthcare providers need to take care to educate themselves on new studies and developments.

I think that healthcare providers need to exercise some self control with regard to ordering tests and treatments.

I think every man with risk factors or symptoms should be screened ASAP.

I think that every man who chooses to be screened needs to educate themselves about prostate cancer and fully investigate the facts and their options.

Remember that as a patient, you have the power to question your provider about the tests and treatments (s)he wants you to have. Take advantage of that. Ask for the reasons behind the recommendations. Don't be afraid to get other opinions. And always remember that you, as a patient, have the right to refuse any tests or treatment.

The PSA test is being blamed for a lot of negatives that it isn't responsible for. The PSA is a simple, inexpensive blood test that indicates whether or not your PSA level is elevated, which MAY be a sign of prostate cancer. The PSA is not responsible for side effects from other tests or treatments; the doctors who ordered and performed them are, and so is the patient who opted to allow them to.

The PSA test isn't the problem. The problem is with doctors that tend to aggressively treat cases without much regard as to whether or not the treatment or additional tests are actually needed. And the problem is with patients who don't take advantage of their right to question providers and to refuse tests and treatment.

Ultimately, the patient is responsible for his or her treatment. We should all take that more seriously.
Hi Russ,

I'm sorry that you had to go through the pain of a prostate biopsy, and I hope everything turns out well for you.

I am curious about your statistics. What type of treatment are you referring to?
It's not the PSA test that's the problem, it's the interpretation of it that's the problem.
Russ Palmieri:

"The studies show you're betting a 1 in 50 chance that your life will be saved (over 10 years) against a 49 in 50 chance that you will be treated unnecessarily. The treatment has a 50% chance of causing sexual problems and a 33% chance of incontinence."

That's what everyone needs to know, in a nutshell.
Everyone also needs to know that you, the patient, have the final word on whether or not you will receive invasive tests and treatments. You, the patient, are allowed to seek out other opinions. You, the patient have options.

If you are treated unnecessarily, most of it's on your doctor, but part of it's on you.
After our extended and rather unsatisfying back-and-forth here, I decided to move my position to my own blog.

For any interested, the post can be found at

http://open.salon.com/blog/sickofstupid/2009/03/21/
what_good_is_an_erection_when_youre_dead

I welcome comments from all posters (even you, Dr. Amy) and will answer any questions asked.
@sickofstupid See my blog post for references to the stats I mentioned. http://open.salon.com/blog/russpalmeri/
@ Dr. Amy

This statement does not appear to be correct:

"You seem to be confused about the purpose of the study. It looked at routine screening for prostate cancer in men who did not have risk factors. People who have risk factors are in a totally different category."

Neither of the studies (Mortality Results from a Randomized Prostate-Cancer Screening Trial or Screening and Prostate-Cancer Mortality in a Randomized European Study) excluded men with risk factors. They excluded men with prior prostate cancer generally.

I feel your article is reckless and irresponsible frankly. Congratulations that it comes up #2 on a Google search "who should be screened for prostate cancer". No one has the answers as of yet but you make a blanket statement "Don't Get Screened".

I hope people read further than this blog and as "sickofstupid" advised, get educated and find a good physician to discuss this issue with.