FYI,
March 10, 2010
Op-Ed Contributor
The Great Prostate Mistake
By RICHARD J. ABLIN
Tucson
EACH year some 30 million American men undergo testing for prostate-specific antigen, an
enzyme made by the prostate. Approved by the Food and Drug Administration in 1994, the
P.S.A. test is the most commonly used tool for detecting prostate cancer.
The test.s popularity has led to a hugely expensive public health disaster. It.s an issue
I am painfully familiar with . I discovered P.S.A. in 1970. As Congress searches for ways
to cut costs in our health care system, a significant savings could come from changing the
way the antigen is used to screen for prostate cancer.
Americans spend an enormous amount testing for prostate cancer. The annual bill for P.S.A.
screening is at least $3 billion, with much of it paid for by Medicare and the Veterans
Administration.
Prostate cancer may get a lot of press, but consider the numbers: American men have a 16
percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent
chance of dying from it. That.s because the majority of prostate cancers grow slowly. In
other words, men lucky enough to reach old age are much more likely to die with prostate
cancer than to die of it.
Even then, 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.
Instead, the test simply reveals how much of the prostate antigen a man has in his blood.
Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can
all elevate a man.s P.S.A. levels, but none of these factors signals cancer. Men with low
readings might still harbor dangerous cancers, while those with high readings might be
completely healthy.
In approving the procedure, the Food and Drug Administration relied heavily on a study
that showed testing could detect 3.8 percent of prostate cancers, which was a better rate
than the standard method, a digital rectal exam.
Still, 3.8 percent is a small number. Nevertheless, especially in the early days of
screening, men with a reading over four nanograms per milliliter were sent for painful
prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always
pushed into surgery, intensive radiation or other damaging treatments.
The medical community is slowly turning against P.S.A. screening. Last year, The New
England Journal of Medicine published results from the two largest studies of the
screening procedure, one in Europe and one in the United States. The results from the
American study show that over a period of 7 to 10 years, screening did not reduce the
death rate in men 55 and over.
The European study showed a small decline in death rates, but also found that 48 men would
need to be treated to save one life. That.s 47 men who, in all likelihood, can no longer
function sexually or stay out of the bathroom for long.
Numerous early screening proponents, including Thomas Stamey, a well-known Stanford
University urologist, have come out against routine testing; last month, the American
Cancer Society urged more caution in using the test. The American College of Preventive
Medicine also concluded that there was insufficient evidence to recommend routine
screening.
So why is it still used? Because drug companies continue peddling the tests and advocacy
groups push .prostate cancer awareness. by encouraging men to get screened. Shamefully,
the American Urological Association still recommends screening, while the National Cancer
Institute is vague on the issue, stating that the evidence is unclear.
The federal panel empowered to evaluate cancer screening tests, the Preventive Services
Task Force, recently recommended against P.S.A. screening for men aged 75 or older. But
the group has still not made a recommendation either way for younger men.
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.
I never dreamed that my discovery four decades ago would lead to such a profit-driven
public health disaster. The medical community must confront reality and stop the
inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue
millions of men from unnecessary, debilitating treatments.
Richard J. Ablin is a research professor of immunobiology and pathology at the University
of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation
for Cancer Research.
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