Just as a new study on the benefits of PSA are published, I received a sad email over PSA ignored.
As I read and reread the following email that I received this morning, sadness and disbelief took hold of me:
My companion/lover/confidante died from prostate cancer on July 20, 2012. In 2005, his PSA was 7. His urologist was unable to find any cancer and told him that an elevated PSA could be caused by a number of things and not to be concerned. He still had an elevated PSA at his next exam and again, a biopsy could not find cancer. Finally, in 2008, he sought another opinion from another urologist who took the PSA and his other symptoms seriously and he was diagnosed with advanced prostate cancer. It had already spread to his lymph nodes. His PSA was now over 200. Incurable. We were “lucky” to be able to fight the progression this long with hormone therapy, chemotherapy and radiation until now. But, if the PSA had been taken seriously in 2005, he would most likely be alive and thriving today. The PSA is a necessary test and can save lives… It was signed, Laurie.
This testimony arrived just on the heels of a new study published this week in the journal Cancer. It gives important counterbalance to the recent recommendation by the U.S. Preventative Services Task Force (USPSTF) against routine prostate-specific antigen (PSA) testing for prostate cancer. The results of this study found that if PSA testing were widely rolled back, three times the number of men would be diagnosed annually with advanced prostate cancer that had spread beyond the organ and is much more difficult to treat. The study showed steep declines in the prevalence of men diagnosed with metastatic prostate cancer around the time PSA testing came into widespread use in the United States in the early 1990s. Currently with widespread PSA testing, some 8,000 U.S. men are diagnosed each year with metastatic prostate cancer; the study calculated that number would be 25,000 if not for PSA testing.
Of course, we all know the downside of regular PSA testing is the risk of overtreatment. Currently there is no definitive way to determine which man diagnosed with early prostate cancer will go on to metastatic disease and which can live comfortable with his non-lethal tumor. The senior author on the study, Dr. Edward M. Messing at the University of Rochester, was quoted in HealthDay as saying that the USPSTF recommendation on PSA testing this year, “wasn’t a brilliant conclusion.”
Dr. Stuart Holden, director of the Louis Warschaw Prostate Cancer Center at Cedars-Sinai Medical Center and the medical director of the Prostate Cancer Foundation, who was not involved in the study, said, “It’s definitely true that wholesale screening using PSA leads to over detection and over treatment, but within that group of men there is a subset of patients—and not an insignificant subset, as shown by this study—that are surely benefited by PSA screening and treatment.”
Dr. Holden also said that he and many other urologists who practiced medicine in the pre-PSA era, have witnessed changes that are undeniably positive in PSA era—meaning doctors see a lot fewer men diagnosed with late-stage prostate cancer that is likely to significantly shorten their lifespans. “It strikes me as horrifying to think someone would make a recommendation which might take us back to that era again,” he said.
In fact, Dr. Holden points out that China is now in a pre-PSA era, where much of the prostate cancer doctors see in that country has progressed to the advanced metastatic stage that is often lethal. Ultimately the answer, both in the U.S. and around the world, will be better science that can, with good accuracy, determine at an early state of diagnosis, which prostate cancer is destined to become lethal and which is so slow-growing that treatment can be avoided.
As a patient with metatstatic disease, I am still a firm believer that the PSA test may have saved my life. I also know that many men have been overtreated. Clarity is needed for fighting this disease. For all the men who will be diagnosed in the coming years, and for men like Laurie’s partner, research for better biomarkers and risk stratification needs to continue.