Some years before his retirement, when my father-in-law went in for his routine physical, his doctor ordered a prostate specific antigen (PSA) test, along with a cholesterol test and blood count. My father-in-law was not having any symptoms, and no one in his family had a history of prostate cancer.
His PSA came back at 4.2 ng/mL (nanograms per milliliter) — slightly above the maximum “normal” level of 4.0 ng/mL. Then a cascade of investigations into the reason for the elevated reading began. Uncertain of the significance of a positive PSA test, he went for a prostate biopsy that required more than a half-dozen needle jabs through his rectum into the prostate.
“Each one made a stapler-like sound. It was uncomfortable and there was some blood in my urine,” he said, “but it went away.”
Like most men at this stage, he was preparing for the worst: a diagnosis of prostate cancer and then the medical slippery slope of CT scans, bone scans, surgery, radiation and chemotherapy. So when the biopsy results came back benign, he felt relief.
Several years ago, my wife, who was in her 40s, had her annual mammogram, “a breast-smashing, barbaric test,” as she describes it. She had had normal test results for a few years, but this time “a mass” was detected and she was scheduled for a biopsy. Anxious and uncertain, we too braced for the worst — and were relieved when the biopsy results were benign.
My mother, due to my insistence, gets an annual ob-gyn checkup and a Pap smear. I know that a Pap smear, when done regularly, reduces the risk of cervical cancer incidence and mortality by at least 80 percent.
As health-conscious, cancer-fearing, immortality-seeking individuals, we Americans have been programmed through marketing campaigns to follow cancer-prevention recommendations. Seventy-five percent of men over the age of 50 have had a PSA test; 67 percent of women over the age of 40 have had a mammogram in the past two years; and 55 percent of women get a Pap smear every year.
But a debate over the need for such routine testing was re-ignited in November when the U.S. Preventive Services Task Force, a government-appointed scientific advisory board, recommended against routine PSA tests to screen for prostate cancer. The same panel last year suggested that a Pap test every three years is as effective as an annual test in the detection of cervical cancer.
Two recently published studies also suggest reducing the rate of mammogram screenings in women under age 50; one went so far as to conclude that “most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.”
In fact, if my father-in-law, my wife and my mother had followed the current Preventive Services Task Force recommendations, for them there would have been no PSA test, no screening mammogram before the age of 50 and no annual Pap smear. As a result, there would have been no subsequent biopsies for my father-in-law or my wife.
Although we have relied on these tests for decades to screen for cancer in otherwise healthy individuals, the truth is that PSA test, the mammogram and the Pap smear are poor screeners — and always have been. The levels of prostate specific antigen — the marker for cancer — can be elevated in men for a variety of reasons, such as a benign prostate enlargement or a prostate infection. A mammogram can be read as suspicious due to a cyst, which is a benign fluid collection. The abnormal cells reported in a Pap smear may be caused by a local infection.
Further, the limitations of these screening tests extend beyond the false positive results that can cause unnecessary alarm. These tests also frequently result in false negative reports that miss the presence of cancer. The PSA test results will be normal in two of every 10 patients with prostate cancer. Mammogram results will be normal in two of every 10 patients with breast cancer. The Pap smear will fail to detect cervical cancer in three of 10 patients.
Both my father-in-law and my wife were grateful when their biopsies came back benign; they felt as if they had skirted cancer and possibly death. But the new guidelines for routine cancer screening suggest that such tests can be potentially harmful to the patients they are intended to help — not directly, but from the followup procedures, which can lead to complications such as infection or, sometimes, treatment of a cancer that would otherwise not have progressed to the point of causing any harm.
It is this latter point that is critically important and difficult for many to understand. When we hear the word “cancer” we envision our death. Our mindset as a society has been to wage a campaign of “search and destroy” against any cancers that may exist in our body. The new thinking among experts calls for a different approach — one that recognizes that as we age, we are often better off if we simply live with some slow-growing cancers.
For example, autopsy studies show that about 40 percent of men in their 50s and 80 percent of men in their 80s have evidence of prostate cancer. Far more men are dying “with” prostate cancer than dying “from” the aggressive form of the disease. Many of the nonaggressive forms of prostate cancer and other cancers such as skin cancer are better left untreated. The problem is that we do not always have effective tests to differentiate an aggressive form of cancer from a nonaggressive one.
“We need better tests,” my wife says, and it’s hard to argue with that. But until new screening methods are developed that result in fewer false positives and false negatives, we need to adjust our expectations of the ones we have. As Virginia Moyer, a professor at the Baylor College of Medicine and head of the Preventive Services Task Force, puts it, we need to get away from the false notion that “if some prevention is good, then more is better.”
So what would “a better test,” as my wife puts it, look like? It should be accurate, inexpensive, easy to administer and noninvasive, like the blood test for the HIV virus, which is 99 percent accurate and costs only about $15. Researchers are pursuing a number of improvements for tests that screen for various types of cancer, including ones for prostate cancer that track blood calcium levels following a PSA test or test urine for a genetic marker. But such tests are years away from being available to the general public.
In the meantime, should we throw away the PSA test, mammography and the Pap smear as tools for the detection of cancers? Absolutely not. But we should certainly rethink how we administer them — limiting these tests to those who may be at higher risk of cancers because of their age, family history or the symptoms they present.
My colleague Dr. Lee Schwartzberg, an oncologist at The West Clinic, which is now part of Methodist Le Bonheur Healthcare, told me, “There is nothing wrong with a PSA. It’s how the physician handles the data. We need to move away from lockstep ordering patterns either up or down into a better discussion of risk and more nuanced decision-making.”
We should remember that guidelines are just recommendations. Doctors need to tailor them to each patient’s situation. When a patient of mine is anxious and requests an inexpensive, noninvasive test that can help put his mind at ease, I am willing to agree to it, as long as the patient is informed about its limitations. The question, though, may be whether private insurers and the Medicare program are willing to pay for such tests.
Many patients and doctors are convinced that the Preventive Services Task Forces is recommending less screening in order to save money and ration health care. I disagree. The task force is a team of medical experts who analyze the research and make recommendations based on health benefits and not costs.
At my annual physical recently, I asked my primary care doctor whether the new recommendations on prostate cancer screening tests would change the way he practices.
“I am still trying to figure them out,” he said. But I think the recommendations will have a huge impact on the practice of primary care doctors — or at least they should. As preventive care becomes more of a priority, doctors and patients face more complex decisions about the need for screening tests and followup procedures. Doctors can only look toward the latest guidelines in deciding when to order tests and when to hold back.
Are we willing to undergo an imperfect screening test? Or should we forgo it?
My wife has elected to continue with annual mammograms in her 40s despite the new research.
“But if I miss a year or two, I am less worried,” she said.
As for me, when I turn 50 in a few years, I plan to skip the PSA test.