As reported by The Hartford Courant, July 14, 2005.

Uncertain Science of PSA Testing

By Garret Condon

Wristbands of every hue - signifying and supporting a host of causes - have become must-have accessories ever since the Lance Armstrong Foundation introduced its canary-yellow "Live Strong" bracelet in May 2004. Last month, the National Prostate Cancer Coalition began offering a baby blue "Do It for Dad" wristband to raise awareness of annual prostate cancer screening tests.

The Washington-based group calls the test a "must," but that advice is at odds with recommendations from several leading groups, including the American Cancer Society and the U.S. Preventive Services Task Force.

Jamie Bearse, a spokesman for the coalition, said one of the aims of the wristband campaign is to "encourage dad to get tested." He said that only about half of American men over 50 get screened annually with a prostate-specific antigen (PSA) test and a digital rectal exam.

Screening has not been shown, however, to reduce the number of deaths from prostate cancer, which is expected to kill more than 30,000 American men this year. It will be another three years before large studies in the United States and Europe determine whether screening for prostate cancer saves lives.

Screening can lead to biopsies, which in turn often uncover cancer or cancer-like cells. But most such cell clusters in the prostate don't cause problems, either because they don't grow, or they grow so slowly that something else causes death. Medical science can't yet distinguish between early cancer that is likely to be deadly and tumors unlikely to cause symptoms.

So when a biopsy reveals cancer, a patient is usually treated. That typically means surgical removal of the prostate or irradiation of the gland. At least half of the men who undergo either treatment are left incontinent or impotent, says Dr. Russell P. Harris, a professor of medicine at the University of North Carolina School of Medicine in Chapel Hill, N.C., and a member of the U.S. Preventive Services Task Force.

Doctors began using the PSA test as a prostate-cancer screening tool in the late 1980s. Since then, about 1 million more men have been diagnosed with prostate cancer than would have been if the PSA test had not been widely used, according to Dr. H. Gilbert Welch, co-director of the VA Outcomes Group at the VA Medical Center in White River Junction, Vt., and author of "Should I Be Tested for Cancer? Maybe Not and Here's Why," published last year. Most of those additional patients probably did not need treatment, said Welch.

Proponents of the PSA test observe that it has dramatically improved prostate-cancer survival. Coalition spokesman Bearse said, "Ninety-nine percent survive prostate cancer if it's detected early." But Welch and others have observed that the striking increase in survival five and 10 years after diagnosis is mainly the result of diagnosing men earlier - when they are unlikely to die whether they're treated or not - and diagnosing men who were not going to die of prostate cancer anyway.

Prostate cancer death rates have been declining since the early 1990s. The age-adjusted mortality rate for prostate cancer dropped 28.5 percent from 1991 to 2002, according to the American Cancer Society. Bearse said his organization attributes this to treatment advances and a big jump in the number of men getting early detection. Harris said screening may or may not help account for the lowered death rate - it's not yet clear.

Just because there is a lot of uncertainty around the PSA test doesn't mean that men shouldn't get it, said Welch. "It just means that you should realize the deal. Does it reduce the number of prostate cancer deaths? We don't really know that. We know that it does diagnose people who would never need to know they have the disease otherwise."

Current guidelines from the American Cancer Society call for doctors to "offer" a digital rectal exam and PSA to patients beginning at age 50, or age 45 for those at higher risk. "Health care professionals should give men the opportunity to openly discuss the benefits and risks of testing at annual checkups," according to the guidelines. The U.S. Preventive Services Task Force concluded "that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen testing or digital rectal examination."

Dr. Peter Albertsen, a professor and chief of urology at the University of Connecticut Health Center, said that both over-promoting the PSA and condemning the test are extreme positions. It can be useful, he said, especially if physicians look at a rapidly rising score over time, which tends to spell trouble. There is a subset of men definitely helped by the PSA. But he acknowledged that overuse of the test has resulted in over-diagnosis.

"It's a dilemma," he said. "A lot of us have been a little bit hesitant to go off and get blue armbands. If you don't tell people the upside potential and the downside potential, I don't think you're doing them a favor. This test creates almost more emotion than science."

Ultimately, he said, he hopes that the PSA test will be replaced by a technology that uses a DNA or protein signature to find potentially deadly cancer so that only the men who need treatment will get it.