Prostate testing's dark side
Terry Dyroff's PSA blood test led to a prostate biopsy that didn't find cancer but gave him a life-threatening infection.
In the emergency room several days later, "I didn't sit, I just laid on the floor, I felt so bad," said Dyroff, 65, a retired professor from Silver Spring, Md. "I honestly thought I might be dying."
Donald Weaver was a healthy 74-year-old Kansas farmer until doctors went looking for prostate cancer. A PSA test led to a biopsy and surgery, then a heart attack, organ failure and a coma. His grief-stricken wife took him off life support.
"He died of unnecessary preventive medicine," said his nephew, Dr. Jay Siwek, vice chairman of family medicine at Georgetown University. "Blood tests can kill you."
Since Friday, when a task force of independent scientists said routine PSA testing does more harm than good, urologists who make a living treating prostate cancer have rushed to defend the test, as have patients who believe it saved their lives.
Less visible are men who have been harmed by testing, as Dyroff and Weaver were. The harm is not so much from the test itself but from everything it triggers — biopsies that usually are false alarms, and treatments that leave many men incontinent or impotent for cancers that in most cases were not a threat.
Once a PSA test suggests a problem, many men can't live with the worry that they might have cancer. And once cancer is found, most men feel they have to treat it, usually at the urging of their urologist.
"There are many men who have had serious consequences from treatment. Those stories don't get told and they are not uncommon," said Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society, which thinks the task force reached "an appropriate conclusion" about the PSA test.
Canadian group defends PSA
Steve Jones, president and CEO of Prostate Cancer Canada, said while PSA testing isn't the be-all, end-all in diagnostic tools — it can't, on its own, prove the presence of cancer — it's the best available test for men 40 and up.
"Every few months there is a study that comes out that is negative about PSA testing," Jones said Thursday at a Prostate Cancer Canada meeting in Halifax.
"All we know is that we listen to our survivors and virtually all of them here have said in some way PSA testing is the red flag that saved their lives."
Elevated levels of PSA, or prostate-specific antigen, in the blood aren't necessarily caused by prostate cancer.
Too much PSA can also be caused by the normal enlargement of the prostate with age, an infection, or recent sex.
"What men use the PSA test for — a very simple blood test — is to raise a warning flag that says there may be something wrong here," continued Jones.
"But also remember: doctors aren't advising every man to get further testing. When they have their PSA test, if the levels are up, they then check their family history, diet, all the other signs that may lead to prostate cancer."
Olivia Chow, the widow of former federal NDP leader Jack Layton, addressed the conference, urging men to get tested in hopes of detecting prostate cancer early.
Layton was diagnosed last year with prostate cancer. He died in August of a second cancer that was never disclosed.
Chow told the crowd that her husband was "relentless" in his campaign for others to seek PSA testing, even before his diagnosis of prostate cancer.
"Jack took the PSA blood test every year because his father had prostate cancer and he knew that he was at risk," she said.
Chow also echoed Prostate Cancer Canada's calls for PSA testing to be covered across Canada.
Jones said some provinces, including Nova Scotia, pay for the test. However, in provinces such as Ontario, he said men have to pay out of pocket for the test without a doctor's referral.
"The onus is on the governments to understand that men shouldn't have to pay for a PSA test just as women don't have to pay for a mammogram," he said.
"I'm not going to criticize men who believe that their lives have been saved by this test," because that's what doctors have told them, Lichtenfeld said. "If you're sitting there and you wet your pants three times a day, you've got to believe it's worth it, that it saved your life."
Many men who agree to a PSA test do not understand what it is. Some common misconceptions:
It shows cancer. In fact, PSA is just a measure of inflammation, and it can be elevated for many reasons besides cancer: normal enlargement of the prostate with age, an infection, even recent sex, a strenuous bike ride or horseback riding.
It's been proven to save lives. Only two large, well-done studies have looked at this, the task force says.
The American study found annual screening did not lower the chances of dying of prostate cancer. However, cancer fear is so great, and belief in the value of screening so ingrained, that half the men assigned to the group not offered PSA tests got one anyway. That made comparisons to the group given annual screening difficult. For that reason, some doctors don't believe the study's conclusion.
The other study, conducted in Europe, found a small benefit for certain age groups screened every two to seven years — not annually. However, one Swedish center had such rosy results that scientists think it may have biased the whole study. If that center is excluded, no benefit from the PSA test is seen.
The task force's stance goes against past advice. Routine PSAtesting has been supported by some advocacy groups and by urologists, the doctors who do the tests and treatments. But it has not been pushed by major scientific groups, the American Cancer Society or the government.
It finds cancer early so you're more likely to survive. About 90 per cent of prostate cancers found through screening are early-stage. Most will grow so slowly they will never threaten a man's life, but there's no good way to tell which ones will.
Research suggests that tumours causing symptoms are more likely to warrant treatment than those that are not. Also, finding aggressive prostate tumours early may not affect how lethal they prove to be; the PSA test may just let men learn of them sooner than they otherwise would.
The task force said that in the European study, the rate of overdiagnosis from PSA screening — finding cancers that do not need to be treated — was estimated to be as high as 50 per cent. Based on that study, 1,410 men would have to be screened, and 48 patients would have to be treated, just to save one life from prostate cancer.
Yet the public perception is that if PSA testing finds a cancer early, it must be good.
Dyroff, the retired professor, agreed to a biopsy after a blip in his PSA. Days later, he ran a high fever, felt weak and faint, and spent three days in the hospital fighting a bloodstream infection. A week later he relapsed and required a combination of intravenous antibiotics to finally recover.
A recent Johns Hopkins University study found surprisingly high rates of hospitalization after prostate biopsies and a 12-fold greater risk of death in those who develop infections.
The need to find a better screening tool is the real message from the task force, said Dr. Christopher Logothetis, prostate cancer research chief at the University of Texas M.D. Anderson Cancer Center in Houston. It may even be that there are better ways to use the PSA — employing it as a baseline test and tracking its rise over time — that might prove better than annual testing.
"If the debate gets reduced to `there's a right and a wrong,' we will lose what we are being told here, which is to search for the path forward," he said.
The cancer society's Lichtenfeld agreed. "Maybe it's time to listen to evidence instead of hope," he wrote in his blog.