Can Men Be Trusted With PSA Screening?

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My daughter is reading Barbara Ehrenreich’s book Natural Causes for a sociology course in college. This week she’s been home for Spring break, catching up on her sleep and getting ahead on course reading. Now, my daughter knows I have strong opinions on prostate cancer screening, so it was a significant moment when she set her book down and announced to me that Ehrenreich was opposed to PSA testing. A fascinating conversation ensued on all the ways American life has been medicalized by the omnipresent medical-industrial complex (my term, not Ehrenreich’s). “Not only do I reject the torment of a medicalized death,” writes Ehrenreich, “but I refuse to accept a medicalized life, and my determination only deepens with age.” She goes on to explain she is unwilling to spend any of her remaining time “in windowless waiting rooms and under the cold scrutiny of machines,” obtaining tests for health concerns that are otherwise undetectable to her.

“Alexa, how old is Barbara Ehrenreich?” I asked the black cylinder on the kitchen counter. Alexa replied that the author is 77.

“Ah, okay,” I said with suddenly greater understanding of Ehrenreich’s position. The average life expectancy of a woman in the United States is just under 79, so who can possibly blame her for not wanting to buy a few more years of existence at the expense of tedious, time-consuming, and sometimes risky medical screening? Nobody could fault her for such a position.

Extracting the Baby From the Bath Water

I’m not okay, however, with Ehrenreich’s position on PSA screening. She writes of PSA tests, by way of her condemnation of mammograms:

There are even sizable constituencies for discredited tests. When the US Preventive Services Task Force decided to withdraw its recommendation of routine mammograms for women under 50, even some feminist women’s health organizations, which I had expected to be more critical of conventional medical practices, spoke out in protest. A small band of women, identifying themselves as survivors of breast cancer, demonstrated on a highway outside the task force’s office, as if demanding that their breasts be squeezed. In 2008, the same task force gave PSA testing a grade of “D,” but advocates like Giuliani, who insisted that the test had saved his life, continued to press for it, as do most physicians.

This is where I get agitated about the ongoing PSA controversy. Ehrenreich, as one would expect of so respected an author, draws on compelling statistical evidence to decry the over-treatment of otherwise indolent prostate cancers. No doubt, too many men have suffered needlessly from unnecessary prostatectomies. A close friend of my father’s was diagnosed with prostate cancer in his seventies and, when his elderly body was subjected to a prostatectomy—a complicated surgery that can take four to six hours—he suffered a massive heart attack and died. I don’t know what his Gleason score (a numerical system for grading prostate tumors) was or how advanced the cancer, but I suspect if he’d been diagnosed today he would have been a candidate for “watchful waiting” rather than surgical intervention. In fact, many physicians recommend that men over 70 not bother with a PSA test. I don’t disagree with that position. But men who can otherwise expect to live another 15 or 20 years stand to benefit significantly from screening.

What gets me agitated about claims like Ehrenreich’s is how much controversy has been attached to PSA screening—not for its inability to detect cancer, which is not in dispute, but for what happens after the screening results come in. PSA tests simply provide a number, which, considered without context, can whip a patient into a panic, resulting in unnecessary psychological distress and, in many cases, unwarranted medical procedures like prostate biopsies and, even, prostatectomies. In other words, we blame the PSA test for the medical profession’s failure to be judicious in recommending treatment—and for the medical consumer’s tendency to freak out based on inconclusive data.

The prostate-specific antigen, the target of PSA testing, isn’t unique to prostate cancer; and an elevated or changing PSA score can be a result of benign prostate enlargement, an infection, and other factors. What’s more, PSA tests can render false positives, necessitating a follow-up screening to determine if the first reading was accurate. So the test isn’t perfect. More imperfect, however, has been the rush to discredit PSA testing—at the potential expense of men whose lives might be saved by screening.

Is that “C” for Caution?

It is significant that the US Preventive Services Task Force (USPSTF) recommendation to which Ehrenreich refers was updated in 2017. According to an article by James Eastham, Chief of Urology Service at Memorial Sloan Kettering,the new guideline states that prostate-specific antigen (PSA) testing for men between age 55 and 69 should be preceded by a conversation between doctor and patient about the risks and benefits of the test.” The USPSTF guideline now gives PSA testing a “C” grade, which means, says Eastham, “there are risks and benefits and a doctor should have a discussion with a patient to help reach a decision regarding whether or not the PSA should be checked.” In other words, PSA testing—like pretty much everything related to medicine—has risks associated with it and should be undertaken thoughtfully. Are we American men such knee-jerk hypochondriacs that we can’t be trusted to ask intelligent questions about a screening? Are we really willing to abdicate our individual responsibility as healthcare consumers to task forces whose recommendations feel as changeable as weather in the Himalayas?

In my forthcoming book, Midpoint: Manhood, Midlife, and Prostate Cancer, I share my experience of being diagnosed with stage-three prostate cancer at the relatively young age of 56. My doctor, like so many others, had elected not to administer PSA tests to men like me, favoring, instead, the digital rectal exam (DRE), by which means a doctor sweeps his finger over the prostate surface to check for concerning bumps. It is worth noting that only part of the prostate is accessible to the doctor’s finger, meaning he or she can easily miss a cancer growing on the “far side” of the gland. When my doctor, a few months from his retirement, decided to have his own PSA checked, he found he had prostate cancer.

Getting Screened, But Getting Educated

This development led him to a change of heart; and he began recommending that his male patients over 55 have their PSA checked to establish a baseline number. As a result of this new recommendation, I added PSA testing to my annual blood-work. Alas, even though six or seven prior DREs indicated my prostate was smooth and problem-free, my PSA test came back flashing red lights. Not only did I have a 2 cm nodule on the left side of my prostate—that area the doctor’s finger couldn’t reach—but the cancer had extended beyond the prostatic capsule and into the tissue surrounding the gland. That’s what they call “locally advanced” prostate cancer.

That PSA test proved nothing short of miraculous for me. Had I gone another few months without being tested, my cancer might easily have spread further—even metastasized—and my prognosis might have been grim. So while I respect and, to a large extent, agree with Ehrenreich’s frustration with the medicalization of life in America, I passionately oppose condemning PSA screening as unnecessary or ill-advised. As with any medical decision, deciding to have one’s PSA tested necessitates familiarity with the facts—and not just the facts from one hastily reviewed website, but from broad reading on the risks, benefits, and controversies associated with screening.

Men over 70 probably needn’t bother being screened; and men under 55 probably needn’t bother as well. Those of us in between, however, should man up and get educated about the second leading cause of cancer death for men in the United States. Then we need to do what the medical profession apparently doesn’t believe we can: make an intelligent decision whether to be screened.

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