When the U.S. Preventive Services Task Force, a group of preventive medicine and primary care doctors, suggested last week that routine prostate screening not be done using the Prostate Specific Antigen test, they not only jeopardized an important tool, but they passed up an opportunity to shine a spotlight on some of the bad doctors who cause the overtest-overtreat cascade in medicine.
Some 28,000 American men die every year of prostate cancer. So, as a primary care doctor, I perform a yearly prostate examination on each middle-aged man I see. I want to do my best to prevent as many of these deaths as possible. If I don't feel an actual prostate nodule, what else can I do to check this deep unseen gland for cancer?
I have always seen the PSA test as much more of a help than a hindrance. If the antigen level is elevated, I know that some kind of inflammation may be going on. If it is normal, I am reassured that all is likely OK.
Every good doctor knows that the PSA isn't specific for cancer; it can increase from infection or simply from the prostate growing with normal aging. The art of medicine means not overreacting to a number. It means looking for trends and seeking other explanations before jumping to an invasive biopsy with its associated risks of infection and bleeding.
But many doctors do overreact, and responsible physicians and the medical community at large can't ignore that. Just last week, a patient told me that a top prostate cancer expert was planning to biopsy him because his PSA had gone from 2.1 to 2.5. Both numbers are still in the normal range. I encouraged my patient to wait.
Let's face it: Doctors -- especially surgeons -- practice in such a litigious climate that they fear not biopsying a prostate and missing a potentially deadly cancer. But it is the defensive doctors and their biopsy needles that are the problems, not the PSA test that brings them there.
The PSA screening has been a breakthrough in medical science. Since the early 1990s, when it was first used, death from prostate cancer has decreased 40 percent. Of course, it isn't just the test that has caused the decline; as a new study in the journal Cancer demonstrates, better surgical and radiological treatments have also contributed greatly to cures and remissions, which have reduced the death rate.
Still, PSA testing leads to early diagnosis. Since testing became routine, there's been a 75 percent decline in diagnoses not made until the cancer has advanced. That means far fewer men with bone pain and chemical castration.
So where is the Preventive Services Task Force coming from? Its members cite two large 10-year U.S. and European studies that seemed to show that the PSA test didn't save many lives. But they appear to have ignored those studies' imperfections, which include inaccurate or nonprotocol PSA measurements and delays in biopsy. The task force members are also clearly worried about the side effects of unnecessary biopsy and surgery -- which include impotence and incontinence -- and focusing on the slow-advancing cases of prostate cancer that wouldn't kill you even if you left them alone.
But some prostate cancers are killers. The task force underplayed the importance of a 15-year Scandinavian study that showed 38 percent fewer deaths from prostate cancer after surgery. Don't forget, even without the PSA, invasive biopsies and surgeries are going to take place. It's just more likely that they will occur too late to save the patient or keep him from the agonies of metastatic disease.
Given the task force recommendations, health insurance companies, both public and private, may soon no longer pay for the PSA test. And that would mean doctors who simply want to perform a comprehensive assessment on their patients will have lost a valuable tool.
Dr. Marc Siegel is an associate professor of medicine and the medical director of Doctor Radio at New York University Langone Medical Center. He is the author of "The Inner Pulse: Unlocking the Secret Code of Sickness and Health."