Life Without P.S.A. Screening: Russian Roulette?

March 10, 2010

Millions of men woke this morning to the news that what had been done to their bodies in the name of stopping prostate cancer, may after all have been “a mistake.” Writing in The New York Times (Tuesday, March 10, 2010), Dr. Richard J. Ablin, who discovered prostate specific antigen in 1970, calls the routine use of P.S.A. to screen for prostate cancer “hardly more effective than a coin toss.” He points out (as many health-care professionals have been unwilling until recently to admit) that men, post treatment, “…in all likelihood can no longer function sexually or stay out of the bathroom for long.”

American men have, according to recent statistics, a 16 % lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 % chance of dying from it, because most prostate cancers are slow-growing:  the cancer you die with, not of.

Dr. Ablin admits, as we all know, that, so far, we can’t distinguish between the cancer that will kill you and the one that won’t.

Who is the “you” in the previous paragraph?  A statistic or a real flesh-and-blood man?

How does Dr. Ablin imagine it feels to wake up and read that your life-altering treatment has been a mistake? What is a statistic to a life?  How many men with rapidly-escalating P.S.A.’s had Gleason Scores of 7 or above and are alive today as a result of this test? Admittedly, my own husband, whose Gleason was a routine 6, might well have been unnecessarily treated, although his P.S.A. velocity at the time of prostate cancer diagnosis was notable.

It may be that Dr. Ablin’s metaphor, the coin toss, is off the point. It has been said that generally one in ten men with a positive biopsy has a fast-moving prostate cancer that will kill if left untreated.

Universal P.S.A. screening may be a coin toss; but its absence returns us to Russian Roulette. P.S.A. tells us that it might be cancer, and if so, a virulent bullet might be in one of several chambers. Surely knowing this is so, and going for a biopsy, painful as it is, is more valuable than ignorance. If, as Dr. Ablin suggests, “testing should absolutely not be deployed to screen the entire population over the age of 50,” then my husband, among others, might have waited long enough to hear the word “metastasis,” or the even more chilling, the words, “your cancer has gone to bone.”

If P.S.A. as a universal screening tool is inappropriate, then rather than scrapping it for the general population, perhaps doctors should learn to educate their patients and partners to the real truth about the likely sexual, urinary and even bowel consequences of treatment. Then men can make a truly informed choice, as many European men do, who choose to watch and wait.

As long as men are alive who have received these treatments in good faith, Dr. Ablin’s argument stands as the ultimate insult to their experience. He shames what he calls profit-driven public health initiatives, but there are men whose lives have been spared, and those lives are worth something after all. The real shame lies in valuing statistics over individuals.

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