Detecting Prostate Cancer

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This letter appeared in the Washington Times.

Dr. Richard N. Atkins argues that early detection of prostate cancer saves lives, that all men should have an annual PSA test to detect prostate cancer, and that those of us who oppose the test do so because of concern about the costs associated with biopsies, which may be necessary following a finding of elevated PSA ("No more prostate excuses," Op-Ed, Friday).

Such arguments obscure some basic facts:

First, there is no consensus in the medical community that PSA reduces the probability of death from prostate cancer. As the National Cancer Institute notes, "using the PSA test to screen men for prostate cancer is controversial because it is not yet known if this test actually saves lives."

Second, the reason many health professionals are skeptical about the PSA has nothing to do with money. It has to do with our concern that the test will identify tumors that never would have killed a man in the first place, causing him to undergo surgical or radiological treatments that cause negative consequences, including impotence and incontinence.

There is an oft-used analogy that puts prostate cancer screening in perspective: If a farmer had three animals -- turtles, rabbits, and birds -- and wished to build a screen to keep the animals on his property, his efforts would have mixed results: The screen is not needed to handle the turtles -- they move so slowly they are not going anywhere. The birds would not be managed by the screen because they would fly away -- off the property. The only animals that would be affected by the screen would be the rabbits: The screen might prevent them from jumping off the property.

Applying this metaphor to prostate cancer, it is clear that the PSA is only useful when it can pick up the rabbits -- those tumors confined to the prostate but with the potential to metastasize. PSA does not help with "turtles," or rather men whose tumors would not threaten them anyway, nor would PSA help with "birds," cases in which the cancer already has spread by the time the PSA results are in.

Men should remain highly skeptical of PSA results and should discuss all options with their physicians, including the option of doing nothing ("watchful waiting") in cases where the tumor appears to be small and non-aggressive.

American Council on Science and Health
New York