The always hot debate over PSA screening for prostate cancer was reignited once again last month when health officials recommended against using PSA as a screening tool for healthy men of all ages. A few years ago, the group recommended against its use in men over 75.
The U.S. Preventive Services Task Force, an independent, federally funded panel, found that the screening didn't necessarily save lives. Further, it wasn't clear that the benefits of screening outweighed the risks of follow-up testing, including unnecessary procedures that can lead to impotence and incontinence.
The criticism came fast and furious, with advocates of screening saying the task force relied too much on two studies with conflicting results.
Some point out that deaths from prostate cancer are down, so the screening must be helping. Other say it's better treatment, not screening healthy men, that's saving lives.
Bottom line: Doctors and patients are in a quandary.
"I have been inundated with calls and emails," said Dr. Julio Pow-Sang, chairman of genitourinary oncology at Moffitt Cancer Center in Tampa. "Men are asking, 'Did I really need treatment?' "
Pow-Sang recently spoke to the Times from a meeting in North Carolina about new treatments, such as high intensity focused ultrasound, which uses heat to destroy cancerous tissue and may mean fewer side effects.
You can hear him speak tonight at Moffitt's International Plaza facility (see box).
What are you going to talk about tonight ?
I will talk about the PSA (prostate-specific antigen) screening controversy, active surveillance as a management option, interventions other than surgery as treatment options, and a new modality called HIFU — that's high intensity focused ultrasound — which is still being tested in the U.S. and is already being used in Europe, Canada, parts of South America and Japan. We are in talks to possibly join the clinical trial and offer it at Moffitt to certain patients.
The advice on prostate cancer used to be straightforward: get a PSA and rectal exam, and if there's cancer, have surgery or radiation. It's much different now.
Yes, and more complicated. To compound the problem, we know that some cancers will progress and some won't. But we don't know which will be aggressive. We are learning about some characteristics of low-grade cancers and those which can be put under active surveillance, but the studies are suggestive, not conclusive. It (the controversy) has brought to the front more awareness that having cancer isn't always a death sentence, and some cancers may just need to be watched, not treated right away,
What's your take on the current state of PSA testing?
With the current PSA we are finding early cancers and over-diagnosing and treating cancers that don't necessarily need to be treated. I'm not upset about the (task force) report. Some groups are furious about it. I say, yes, the report raises questions, but it also calls for men to have a discussion with their doctor and make an informed decision about whether to proceed with screening and treatment.
What's the downside of PSA screening and treatment?
The PSA has limitations. It has a false positive rate of around 80 percent, meaning that if 100 men with elevated PSA have a biopsy, only 20 will have cancer.
With treatment, we are exposing patients to side effects such as incontinence and erection problems, unnecessarily. Biopsy, anesthesia, surgery, radiation all carry health risks. Death from prostate cancer surgery is about 0.1 to 0.5 percent. That's 1 to 5 men in a thousand will die from a procedure they might not have needed.
How do you help a patient decide?
My bias is to discuss it and take a lot of time talking about it. It's not going to happen in a 15-minute visit. It takes two or three conversations with a specialist. It's a matter of hours and days, not minutes. And if asked for an opinion, I will still recommend a baseline PSA.
Have you ever had a PSA screening?
I did have a PSA screening at age 50 and was very relieved after I found that the result was within normal for my age. I check the levels now every 3 to 4 years and will continue to do so.
What would help?
We need a test that is more precise, one that helps us identify the cancers that won't kill patients and those that are more aggressive. There are several molecular tests on the horizon which might tell us which cancer is more active and likely to progress. Another test looks for specific gene proliferation. But these all need to be validated. I believe we will have something better in the next five years.
Men also need to do their homework so they fully understand the risks and consequences of screening and treatment. At Moffitt, we are developing materials that are accessible on all platforms so men can learn about it, also to help primary care doctors advise their patients.