This article first appeared in the St. Louis Beacon, Oct. 18, 2011 - Medical experts haven't mentioned it yet, but the proposal to limit screening for prostate cancer might be applauded as a way to shave about $2.5 billion off the nation's medical bill.
An estimated 30 million men spend $3 billion annually to get the screening, but a federal task force has just concluded that most men don't need the procedure. While not putting a price tag on this proposed shift in policy, the task force did say some patients were being needlessly harmed by treatment they did not need.
This tentative recommendation, based on a review of major PSA studies by the U.S. Preventive Services Task Force, undoubtedly has injected lots of confusion and uncertainty into the debate about the value of PSA screening. PSA is a protein produced by the prostate gland. Blood is drawn to check the level of protein against age-related standards. If adopted, the recommendation of the task force would reverse a federal policy in effect since 1994. That's the year the FDA urged men age 50 or older to get the test because elevated PSA levels might signal prostate cancer, although elevation could be caused by other factors.
One who concedes that the proposed new screening guidelines might have generated more confusion than clarity is Dr. Gerald Andriole, a prostate cancer expert at the Siteman Cancer Center at Washington University School of Medicine. He's also the principal investigator for the National Cancer Institute's prostate, lung, colorectal and ovarian screening trial.
"I would hate to think men read a headline that says 'PSA No Good' and decide to never get a PSA (test)," he says, "because there are some men who really need a PSA. The announcement, the way it came out, was a little bit of a disservice. We have to have a more nuanced approach to who gets screening. It's the high risk men who need it."
That nuanced approach, he says, would take into account those who are high risk. These include both African-American men and men with a family history of two or more cases of prostate cancer, he says. Aside from the way the task force's work was reported, there was concern among some about what insurers might do next.
"What's worrying me is that some insurance company might quit paying for PSA screening" across the board, Andriole says. "That would be really devastating. The result would be that it would be harder for men who really need PSA testing to get it because they would have to pay for it."
The task force will seek public comment for 30 days before deciding whether to move forward with the changes, amend them or scrap them. In the meantime, Andriole is among physicians trying to explain what's behind the recommendations.
"We're overdoing screening," he says. "What's bad about mass screening is that if we just took about 100 men and all we knew about them was that they were all over the age of 50, we know that 3 percent of those men are destined to die of prostate cancer and 97 of them are not."
Some of the 97 men might end up undergoing needless medical procedures, Andriole says.
"That's why the task force says the horrors done to those 97 men are worse than the benefits that are received by the 3 percent of men," he says.
The new strategy, he says, is to use PSA tests to make judgments about men in the high-risk populations or men whose PSA levels are rising at a rapid rate.
"The bottom line is that there are populations of men who have much higher than the 3 percent chance of dying of prostate cancer. For example, if we screen a group of 100 African-American men, probably 15 of them would benefit from the screening. So the risk-benefit ratio is much more in favor of screening men with high risks for prostate cancer."
Others who should be screened, he says, include all men whose PSA levels are found to be rising rapidly.
If the federal government adopts the task force's recommendation, savings are not guaranteed. Some doctors and patients might choose to ignore the recommendation, seeing screening as insurance against the disease.
Vitamin Warnings
By coincidence, the PSA screening debate began about the same time as studies about the connection between vitamins and health issues, including cancer. In one trial that included 35,000 men, researchers found that those consuming vitamin E had a significantly higher risk of developing prostate cancer. The findings were reported in the Oct. 12 issue of the Journal of the American Medical Association.
The study said researchers found a 17 percent increase in prostate cancer among generally healthy men in the United States, Canada and Puerto Rico. The findings, it says, "demonstrates the potential for seemingly innocuous yet biologically active substances such as vitamins to cause harm."
A separate study, published last week in the Archives of Internal Medicine, disclosed that women taking dietary supplements risked a slightly higher chance of dying. Doctors say some people might need vitamins, David Schardt of the Center for Science in the Public Interest told the Associated Press that researchers are finding that vitamins aren't "as harmless as the industry might have us believe."
Andriole of the Siteman Center says he is more familiar with the PSA controversy than the vitamin issue.
"The way I would explain it is that we made our best guess in the early 1990s when PSA was first coming out about the best way to use it," he says. "But over the past 20 years, we've learned a lot. Now we know that we should use it in high risk populations. And we should use it in a slightly different way."
Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.
